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UNITED STATES OF AMERICA. 



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A TREATISE 



THE DISEASES 



INFANCY AND CHILDHOOD 






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J. LEWIS SMITH, M.D.. 

CLINICAL PROFESSOR OF DISEASES OF CHILDREN IN BELLEVUE HOSPITAL MEDICAL COLLEGE ; PHYSICIAN TO 

CHARITY HOSPITAL; PHYSICIAN TO THE N. Y. FOUNDLING ASYLUM; CONSULTING PHYSICIAN TO 

THE N. Y. INFANT ASYLUM ; CONSULTING PHYSICIAN TO THE CLASS OF CHILDREN'S 

DISEASES, BUREAU FOR THE RELIEF OF THE OUTDOOR POOR, BELLEVUE. 



SIXTH EDITION, THOROUGHLY REVISED. 




WITH FORTY ILLUSTRATIONS. 




PHILADELPHIA: 

LEA BEOTHEES & CO 

1886. 



\ 




Entered according to the Act of Congress, in the year 1885, by 

LEA BROTHERS & CO., 
In the Office of the Librarian of Congress. All rights reserved. 



PHILADELPHIA : 
DOBNAN, PRINTER, 

634 Filbert Street. 



PREFACE TO THE SIXTH EDITION. 



In preparing the Sixth Edition, the author has revised the text 
to such an extent, that a considerable part of the book may be 
considered new. Such thorough revision was required by the 
advancement of our knowledge of the diseases of children since the 
last edition was issued. Some of the important maladies in the 
book have been entirely rewritten, such as cerebro-spinal fever, 
scarlet fever, pseudo-membranous croup, and infantile diarrhoea, and 
the treatment of many of the diseases has been revised. The index 
has been prepared by J. Lewis Smith, Jr., physician to the Class of 
Children's Diseases, in the Bureau for the Relief of the Outdoor 
Poor, Bellevue. 



No. 62 West 56th St., New York, 
January 1, 1886. 



J. L. S. 



(iii) 



PREFACE TO THE FIFTH EDITION 



The constant endeavor of the author, as successive editions of this 

treatise have been called for, has been to make it more useful to the 

medical student and to the physician in his daily practice. He has 

avoided discussion of theories, except as they influence practice, while 

he has devoted more space to the therapeutics of the various diseases. 

He has been stimulated to this by constant intercourse with physicians, 

so as to be able to appreciate their wants, and by letters of inquiry 

sent by physicians, which, for the most part, relate to matters of 

treatment. 

J. L. S. 
No. 227 West 49th St., New York, 
September 16, 1881. 

(v) 



LIST OF ILLUSTRATIONS, 



1. Case of deformity of foetus due to injury of mother 

2. Milk globules 

3. Colostrum-corpuscles 

4. Case of meningocele ...... 

5. Case of rachitic deformity of thorax and abdomen 

6. Skeleton of rachitic infant .... 

7. Head of rachitic infant ..... 

8. Eachitic spinal curvature in adult 

9. Cases of rachitic deformity of head and ribs 

10. Deformity of chest in rachitis .... 

11, 12, 13. Rachitic deformity of pelvis . 
14, 15. Eachitic deformity of the femur 

16, 17. Eachitic deformity of the tibia and fibula . 

18. Scrofulous dactylitis 

19. Case of strumous inflammation of the joints 

20. Case of bronchial phthisis . 

21. Bacillus tuberculosis . 

22. Case of dactylitis syphilitica 

23. Development of the teeth in syphilis 

24. Deformity from pertussis . 

25. Position in cerebro-spinal fever 

26. Case of rheumatic deformity 

27. Case of acephalus 

28. Case of congenital hydrocephalus 

29. Case of congenital hydrocephalus 

30. Outline of head in acquired hydrocephalus 

31. Case of facial paralysis 

32. Case of pseudo-hypertrophic paralysi 

33. Case of spina bifida . 

34. Microscopic appearance in emboligmal pneumonia 

35. Case of gangrene of mouth 

36. Intussusception .... 
37 to 40. Acarus scabiei . 



PAGE 

22 
34 
34 
75 
101 
107 
120 
121 
122 
123 
124 
125 
126 
129 
147 
162 
173 
183 
184 
333 
359 
401 
416 
443 
445 
451 
539 
541 
548 
611 
675 
791 
854 



( vii ) 



CONTENTS. 



PAET I, 

CHAPTER I. 

PAGE 

Infancy and Childhood . . .17 

CHAPTEE II. 

Care of the Mother in Pregnancy ........ 19 

CHAPTEE III. 

Mortality of Early Life: Its Causes and Prevention . . . .23 

CHAPTEE IV. 

"Weight, Growth, Lactation .28 

Hindrances to Lactation and Physical Conditions Eendering it Improper — 
Colostrum — Human Milk — Modification of Milk in Consequence of the 
Diet — Modification of Milk from its Eetention in the Breast — Modifica- 
tion of Milk by Age and by Mental Impressions — Modification of Milk by 
the Catamenial Function, Pregnancy, and Other Causes — Differences in 
Suckling Women as Eegards Quantity and Quality of Milk — Scantiness 
of Milk ; its Causes and Treatment. 

CHAPTEE V. 
Selection of a Wetnurse 44 

CHAPTEE VI. 
Course of Lactation — "Weaning 48 

CHAPTEE VII. 
Quantity of Eood Eequired in Infancy and Childhood . . .51 

CHAPTEE VIII. 
Artificial Feeding . . 57 

CHAPTEE IX. 

Bathing, Clothing, Sleep, Exercise 66 

Clothing — Sleep — Exercise. 

(ix) 



CONTENTS. 



CHAPTER X. 

PAGE 

Diseases of the New-born .71 

Apncea (Asphyxia) Neonati — Caput Succedaneum — Cephalhematoma — 
Meningocele, Encephalocele, Hydrencephalocele. 

CHAPTER XL 
Ophthalmia Neonati . . 77 

CHAPTER XII. 

Diseases of the Umbilicus . . .82 

Thrombosis and Phlebitis of the Umbilical Vein, Septicaemia of the New- 
born — Inflammation and Ulceration of Umbilicus — Umbilical Granula- 
tions or Fungus. 

CHAPTER XIII. 
Umbilical Hemorrhage 87 

CHAPTER XI V. 

Diagnosis of Infantile Diseases 90 

General Observations — Features, External Appearance of Head, Trunk, 
and Limbs in Disease — Attitude — Movements — The Voice — Respiratory 
System — Circulatory System — Animal Heat — Digestive System — Ner- 
vous System. 

CHAPTER XV. 
Therapeutics ... 103 



PAET II. 

CONSTITUTIONAL DISEASES. 

SECTION I. 

DIATHETIC DISEASES. 
CHAPTER I. 

Rachitis . . . 105 

Frequency of Rachitis — Age at which Rachitis Occurs — Causes of Rachitis 
— Artificial Production of Rachitis — Anatomical Characters of Rachitis 
— Symptoms of Rachitis — Complications and Sequelae of Rachitis — Diag- 
nosis of Rachitis — Prognosis of Rachitis — Treatment of Rachitis. 

CHAPTER II. 

Scrofula 135 

Strumous Ophthalmia. 



CONTENTS. XI 



OHAPTEK III. 

PAGE 

Tuberculosis 153 

CHAPTEE IV. 
Syphilis 177 



SECTION II. 

ERUPTIVE FEVERS. 

CHAPTER I. 

Measles 188 

CHAPTER II. 
Scarlet Fever 197 

CHAPTER III. 

ROTHELN 265 

CHAPTER IV. 
Variola — Varioloid 274 

CHAPTER V. 

Vaccinia 283 

Subsequent Vaccinations — Protection from Vaccination — Revaccination — 
Selection of Virus 

CHAPTER VI. 
Varicella 293 



SECTION III. 

NON-ERUPTIVE CONTAGIOUS DISEASES. 
CHAPTER I. 

Diphtheria 295 

Pertussis 

CHAPTER II. 
Parotiditis 339 



Xll CONTENTS. 

SECTION IV. 

OTHER GENERAL DISEASES. 

CHAPTER I. 

PAGE 

Intermittent Fever . 342 

CHAPTER IT. 
Remittent Fever . 347 

CHAPTER III. 
Typhoid Fever 348 

CHAPTER IY. 
Cerebrospinal Fever 358 

CHAPTER V. 
Acute Rheumatism 398 

CHAPTER VI. 
Erysipelas 404 



PAET III. 

SECTION I. 

DISEASES OF THE CEREBRO-SPINAL SYSTEM. 

CHAPTER I. 

Acephalus — Anencephalus 415 

CHAPTER II. 

Imperfect Brain 4L7 

Microcephalia — Atrophy of Brain 

CHAPTER III. 
Hypertrophy of Brain 420 

CHAPTER IV. 
Thrombosis in the Cranial Sinuses (Phlebitis) 424 

CHAPTER V. 
Congestion of the Brain 429 



CONTENTS. Xlii 



CHAPTER VI. 

PAGE 

Intracranial Hemorrhage (Meningeal Hemorrhage; Cerebral Hem- 
orrhage) 433 

CHAPTER VII. 
Congenital Hydrocephalus 442 

CHAPTER VIII. 
Acquired Hydrocephalus 449 

CHAPTER IX. 

Meningitis, Tubercular and iSTon-tubercular . . . . . 452 

CHAPTER X. 
Spurious Hydrocephalus ■ 470 

CHAPTER XL 
Eclampsia 476 

CHAPTER XII. 
Tetanus Infantum 485 

CHAPTER XIII. 
Internal Convulsions 504 

CHAPTER XIV. 
Chorea 512 

CHAPTER XV. 
Infantile Paralysis 528 

CHAPTER XVI. 

Facial Paralysis 538 

Paralysis with Pseudo-hypertrophy. 

CHAPTER XVII. 

Diseases of the Spinal Cord and its Coverings 544 

Congestion of the Spinal Cord and its Membranes. 

CHAPTER XVIII. 
Spina Bifida 547 

CHAPTER XIX. 
Vertebral Caries 551 



XIV CONTENTS. 

SECTION II. 

DISEASES OF THE RESPIRATORY SYSTEM. 
CHAPTER I. 

PAGE 

Coryza 556 

CHAPTER II. 

Catarrhal Laryngitis 559 

Spasmodic Laryngitis. 

CHAPTER III. 

Membranous Croup; Diphtheritic Croup; True Croup . . . 567 

CHAPTER IV. 
Bronchitis 593 

CHAPTER V. 
Atelectasis 605 

CHAPTER YI. 
Pneumonitis 609 

CHAPTER VII. 

Pleuritis 622 

Nervous Cough. 

SECTION III. 

DISEASES OF THE DIGESTIVE APPARATUS. 

CHAPTER I. 

Simple Stomatitis, Ulcerous Stomatitis, Follicular Stomatitis . 663 
Simple or Catarrhal Stomatitis — Ulcerous Stomatitis — Aphthous Stomatitis. 

CHAPTER II. 
Thrush ...'.... 669 

CHAPTER III. 
Gangrene of the Mouth 673 

CHAPTER IV. 
Dentition 680 

Second Dentition. 

CHAPTER V. 

Catarrhal Pharyngitis, Peri-pharyngeal Abscess, Oesophagitis . 687 



CONTENTS. XV 



CHAPTER VI. 

PAGE 

Indigestion, Congestion of Stomach, Gastritis, Follicular Gastritis, 

Diphtheritic Gastritis, Post-mortem Digestion, Softening . . 697 
Congestion of the Stomach — Gastritis — Follicular Gastritis — Diphtheritic 
Gastritis — Post-mortem Digestion — Softening. 

CHAPTEE VII. 

Diarrhoea 713 

Non-inflammatory Diarrhoea. 

CHAPTER VIII. 

Intestinal Catarrh of Infancy (Entero-colitis) .... 718 

Cholera Infantum, or Choleriform Diarrhoea. 

CHAPTER IX. 
Enteritis and Colitis in Childhood 747 

CHAPTER X. 
Constipation . 750 

CHAPTER XL 
Intestinal Worms 765 

CHAPTER XII. 
Gastro-intestinal Hemorrhage 781 

CHAPTER XIII. 

Intussusception . 787 

Intussusception without Symptoms — Intussusception with Symptoms — In- 
tussusception in the Small Intestines — Intussusception in Large Intes- 
tines. 

SECTION IV. 

DISEASES OF THE GENLTO-URINARY ORGANS. 

Uric Acid Infarctions — Enuresis — Calculi, Dysuria, Cryptorchia — Vulvitis . 810 

SECTION V. 

DISEASES OF THE CIRCULATORY SYSTEM. 

CHAPTER I. 

Cyanosis .- 823 

Literature of Cyanosis — Sex — Causes of the Malformations — Symptoms — 
Prognosis — Mode of Death — Modes of Compensation — Morbid Anatomy 
— Theories Relating to the Etiology of Cyanosis — Treatment. 



xvi CONTENTS. 

i 

SECTION VI. 

SKIN DISEASES. 
CHAPTER I. 

PAGE 

Erythematous Diseases 840 

Erythema — Roseola — Urticaria. 

CHAPTER II. 

Papular Diseases 846 

Strophulus. 

CHAPTER III. 

Eczema 847 

Scabies 854 



THE 



DISEASES OF CHILDREN 



PART I 



CHAPTEE I. 

INFANCY AND CHILDHOOD. 

Infancy and childhood are, in certain respects, the most important 
and interesting periods of life. To the physiologist they are especially 
interesting, because they are the periods of development and of greatest 
functional activity; to the pathologist, because in them many diseases 
occur which are rarely or never observed in the other periods, or which 
present in these periods peculiar features; to the physician and vital 
statistician, because in them there are the greatest amount of sickness 
and largest number of deaths. 

Infancy extends from birth to the age of two and a half years, or 
till the completion of first dentition. In infancy the organs are delicately 
organized, containing a large proportion of water, and hence are easily 
injured. In this period the brain is rapidly developed — more so than 
any other organ; animal matter predominates in the bones; the arteries 
are relatively large, the muscles small ; the superficial veins are small. 
Fat is absent from the interior of the body, but abundant, in well- 
nourished infants, underneath the integument. The skin is delicate, 
and its temperature not much below that of the blood. At birth it has 
a reddish hue, and is covered with soft, fine hairs (lanugo). The reddish 
hue gradually fades into the healthy tint of infancy, and the hairs fall 
out. In the first two months the sweat-glands have little functional 
activity, sensible perspiration being quite rare. Subsequently perspira- 
tion is freer, and in certain diseased states (rachitis, etc.) is abundant. 
The sebaceous glands in the first half of infancy are active, particularly 
upon the scalp, producing often a pale yellow incrustation, consisting of 
sebaceous matter and epidermic cells. 

The secretions from the mucous surfaces commence at an early period. 
At birth the surface of the digestive tube is covered w T ith more or less 
mucus, often in considerable quantity. The meconium is not considered, 
as formerly, to be a product of intestinal secretion. It consists of flat 

2 ( 17 ) 



18 INFANCY AND CHILDHOOD. 

epithelial cells, fine hairs, oil-globules, crystals of cholesterin, and 
brownish or yellowish masses of coloring matter probably from the 
liver. It is supposed that, with the exception of the coloring matter, 
the meconium is derived mainly from the amniotic fluid which the foetus 
has swallowed. 

The most wonderful change occurring in the system at birth, through 
the exigencies of the new life, is that in the circulation. The flow of 
blood being interrupted, thrombi form in the umbilical vein and arteries, 
and in the ductus arteriosus and ductus venosus, and these vessels 
gradually atrophy, becoming finally shrivelled but permanent cords. 
I have many times at autopsies removed the plug from the ductus 
arteriosus when death had occurred as late as the third week. The 
foramen ovale closes slowly. I have ordinarily found it open till near 
the end of the first half year, but the valve covers fully the aperture, 
so that there is no detriment to the circulation. Both the pulse and 
respiration are more frequent during infancy than childhood, and are 
more accelerated by moral and physical causes. 

The stomach has a smaller relative size and emesis is more readily 
caused than in the adult. The liver is large, occupying at birth nearly 
half of the abdominal cavity, but it grows smaller in successive months. 
The appetite is good and digestion active, so that hunger, when appeased, 
soon returns. The thymus gland, at birth about the size of an 
expanded lung, slowly atrophies, but it does not totally disappear 
till after infancy. 

The kidneys, distinctly lobulated at birth, gradually change their 
form, so as to present in the last part of infancy nearly the shape of 
the organ in the adult. The renal secretion commences early, even 
before birth. The kidneys seldom undergo degenerative changes as in 
the adult, but they are liable to congestions and inflammations. 
During the first month, and especially the first fortnight, crystals of 
uric acid, and the urates, are often found in the urine, in a state of 
apparent health, causing more or less fretfulness in their elimination, 
staining the diaper, and not infrequently being arrested in the tubules 
of the pyramids, where they can be seen as pink-colored spots or lines 
(uric acid infarction). These deposits of uric acid and the urates may 
even occur in the foetus, producing obstruction and inflammation of the 
renal tubes. Congenital cystic degeneration of the kidneys is, in the 
opinion of Virchow, clue to them. In early infancy the senses are 
imperfectly developed, the eyes being attracted only by bright objects, 
and the sense of hearing affected only by loud noises. Sleep is the 
normal state in the first weeks of life ; as the age of the infant 
increases, less and less sleep is required ; but the oldest infants need 
more than children, and several hours more than adults. 

The new-born infant is apparently destitute of mental faculties. It 
seeks the breast by instinct, and it exhibits no perception or reflection. 
The loud cries with which it commences its existence are not from 
anger or suffering ; they appear to be normal, like the act of nursing, 
and providentially designed, in order to expand the lungs. It is not 
till the close, or near the close, of the first month, that the gray sub- 
stance of the brain begins to appear — the probable seat of the mind, 



CARE OF THE MOTHER IN PREGNANCY. 19 

and the source of all mental phenomena. Perception and curiosity are 
early manifested. The infant, as Edmund Burke has remarked, is con- 
stantly seeking new objects for its amusement, rejecting old playthings 
for such as possess more novelty. Reflection, a higher faculty of the 
mind, appears at a later period. The mind and the bodily organs in 
infancy are, in a high degree, impressionable. Anger is excited by 
trivial causes, but is easily appeased ; and the various functions in the 
system are disturbed by agencies which in youth or manhood would 
have no appreciable effect. 

Childhood extends from infancy to the age of fifteen years or 
puberty. It is a period of great physical activity, and of rapid growth. 
The functions of the various organs are performed with more modera- 
tion than in infancy, and are less frequently deranged. The volume 
of the brain continues to increase rapidly, and it becomes firmer than 
in infancy. It is estimated that by the seventh year the weight of this 
organ has doubled. The mind now exerts a controlling influence over 
the actions of the individual. The digestive organs have changed, so 
that solid food is required. Most of the glandular organs are less 
active than in the greater part of infancy, and some of them, as the liver, 
are relatively smaller. The pulse and respiration gradually become less 
frequent as the child advances in age. 



CHAPTEE II. 

CAEE OF THE MOTHEK IN PREGNANCY. 

The frequency of miscarriages and still-births, and the large number 
of ill-formed and puny infants, born to a precarious and short existence, 
render imperative, on the part of the mother, a strict observance of the 
laws of health, and an avoidance of all exciting or perturbating influences 
during the time when the foetus is being developed. The diet should 
be plain and easily digested, but nutritious. There is often a craving 
in pregnancy for unusual articles of food. These may sometimes be 
allowed within certain limits, provided that they are such as do not 
derange the stomach. Meats and animal broths, together with vege- 
tables and farinaceous food, should constitute the ordinary diet, and 
should be taken at regular intervals. 

Daily exercise, never violent, but moderate and gentle, is requisite. 
No exercise is better, none safer and more likely to contribute to cheer- 
fulness and healthy functional activity of the organs, than the ordinary 
household duties. Lifting heavy weights, or work which, like washing 
and ironing, causes great and continued action of the abdominal muscles, 
should be avoided. Such exercise is highly injurious, and is apt to 



20 CAKE OF THE MOTHER IN PREGNANC1 . 

produce premature labor. Exercise in the open air, on foot, or by an 
easy conveyance, conduces to the health of the mother and the growth 
and development of the foetus. On the other hand, rapid riding over 
rough roads is one of the most dangerous modes of exercise. It Las 
been known to destroy the foetus, which up to that time had been ap- 
parently vigorous. When such a result occurs, there is probably more 
or less detachment of the placenta. 

It being a matter of the utmost importance that the health of the 
mother should continue good during gestation, any disease which she 
may have in this period, and which affects her nutrition or the character 
of her blood, should be promptly cured if practicable, and with the 
least possible reduction of the vital powers. Intermittent fever, occur- 
ring during gestation, should never be allowed to continue. It seriously 
retards foetal development, and may produce miscarriage. Unless it be 
controlled by proper measures, the offspring, though born at term, is 
puny and emaciated. Syphilis, in the pregnant woman, also requires 
treatment. This disease, readily transmitted from the mother to the 
foetus through the ovum or the uterine circulation, may be eradicated 
by anti-syphilitic treatment of the mother, or at least so modified that 
the infant is born vigorous and healthy. 

The pregnant woman should avoid all causes of undue mental excite- 
ment. This is almost as necessary as the avoidance of great physical 
exertion. There is, during pregnancy, unusual susceptibility to mental 
impressions, and this should be borne in mind not only by the woman 
herself, but by those who associate with her. 

Strong emotions, whether of joy, sorrow, or anger, affect primarily 
the nervous system, but indirectly most of the organs of the body. 
Observations have long established the fact that such emotions influence 
the state and functions not only of the digestive and glandular, but 
muscular organs, as the heart and uterus. Physicians are familiar with 
cases in which vivid mental impressions produced uterine contractions, 
and even miscarriage, or have disturbed the catamenial function. 
Therefore, the associations and cares of pregnant women should be such 
as conduce to cheerfulness and equanimity. 

It is the popular belief, and the belief of many physicians, that vivid 
mental impressions sometimes have a direct effect on the development 
of the foetus. Many cases are on record in which infants were born 
with marks or deformities corresponding in character with objects which 
had been seen and had made a strong impression on the maternal mind 
at some period of gestation. Whether the mind of the mother exert a 
controlling influence on the form and color of the foetus, is a subject of 
great interest to the psychologist as well as the physiologist and physi- 
cian, since it involves no less a question than the power and scope of 
the human mind. Violent emotions, it is admitted, may affect directly 
most of the important organs in the system. They may derange the 
liver, causing jaundice, accelerate, or for a moment suspend, the heart's 
action, stimulate the kidneys, causing diuresis, or even the intestinal 
follicles, causing watery evacuations. But with all these organs the 
brain is connected by nerves which anatomy reveals. On the other 
hand, the mother and foetus have a distinct existence as regards their 



MATERNAL IMPRESSION'S. 21 

nervous systems, and even their blood. Still, the multitude of facts 
which have accumulated justify the belief that deformity, or other 
abnormal development of the foetus is, at times, due to the emotions of 
the mother. Some of the cases related by Dr. Whitehead, in his work 
on hereditary diseases, are very striking and difficult to explain on the 
ground of coincidence. I have met the following cases. An Irish 
woman of strong emotions and superstitions was passing along a street 
in the first months of her gestation, when she was accosted by a beggar, 
who raised her hand, destitute of thumb and fingers, and in " God's 
name " asked for alms. The woman passed on ; but reflecting in whose 
name money was asked, felt that she had committed a great sin in re- 
fusing assistance. She returned to the place where she had met the 
beggar, and on different days, but never afterward saw her. Harassed 
by the thought of her imaginary sin, so that for weeks, according to 
her statement, she was made wretched by it, she approached her con- 
finement. A female infant was born, otherwise perfect, but lacking the 
fingers and thumb of one hand. The deformed limb was on the same 
side, and it seemed to the mother to resemble precisely that of the 
beggar. In another case which I met, a very similar malformation was 
attributed by the mother of the child to an accident occurring to a near 
relative, which necessitated amputation during the time of her gesta- 
tion. I examined both of these children with defective limbs, and have 
no doubt of the truthfulness of the parents. In May, 1868, I removed 
a supernumerary thumb from an infant, whose mother, a baker's wife, 
gave me the following history : Xo one of the family, and no ancestor, 
to her knowledge, presented this deformity. In the early months of 
her gestation she sold bread from the counter, and nearly every day a 
child with double thumb came in for a penny roll, presenting the penny 
between the thumb and the finger. After the third month she left the 
bakery, but the malformation was so impressed upon her mind that she 
was not surprised to see it reproduced in her infant. 

Professor William A. Hammond, of this city, in an interesting paper 
on the " Influence of the Maternal Mind," etc. (Quarterly Journal of 
Psychological Medicine, January, 1868), says : " The chances of these 
instances, and others which I have mentioned, being due to coincidence, 
are infinitesimally small, and though I am careful not to reason upon 
the principle of post hoc, ergo propter hoc, I cannot, nor do I think 
any other person can, no matter how logical may be his mind, reason 
fairly against the connection of cause and effect in such cases. The 
correctness of the facts can only be questioned ; if these be accepted, 
the probabilities are thousands of millions to one that the relation 
between the phenomena is direct." Professor Dalton also says (Human 
Physiology): " There is now little room for doubt that various defor- 
mities and deficiencies of the foetus, conformably to the popular belief, 
do really originate in certain cases from nervous impressions, such as 
disgust, fear, or anger, experienced by the mother." The observations 
on which this belief is based relate both to man and the lower animals. 
A very strong argument in its support is, as Professor Hammond 
remarks, the popular opinion, which dates back to the time of Jacob. 
(Genesis xxx.) An almost universal sentiment, running through centu- 



22 



CARE OF THE MOTHER IX PREGNANCY. 



ries, is rarely wholly fallacious. It has some truth for its foundation, 
especially when, as in this instance, the subject is one of observation. 

If maternal emotions affect the development of the exterior of the 
foetus, as observations show, and physiologists admit, the presumption 
is strong that they may affect also the proper development and adjust- 
ment of the parts of the brain, an organ so complex and delicate, and 
may therefore give rise to idiocy. Dr. Seguin (Idiocy and its Treat- 
ment, etc., New York, 1866) thus remarks on this point : " Impressions 
will, sometimes, reach the foetus in its recess, cut off its legs or arms, 
or inflict large flesh wounds, before birth, . . . from which we 
surmise that idiocy holds unknown though certain relations to maternal 
impressions, as modifications to placental nutrition." 

It is an interesting fact that abnormalities of structure, occurring 
from whatever cause, are apt to be propagated to descendants. Dr. 
Carpenter and others relate instances among the lower animals, and 
similar instances of transmission have now and then been observed in 
the human race. Thus, in the issue of Nature for March 7, 1878, 
it is stated on the authority of M. Lenglen, a physician of Arras, that 
a certain M. Gamelon in the last century had two thumbs on each hand, 
and two great toes on each foot ; this peculiarity did not appear in the 
son, but it reappeared in the three succeeding generations, so that some 

of the great-great-grandchildren 
Fig. 1. possessed it in as marked a degree 

as their ancestors. 

In view of such important facts, 
the duty of the pregnant woman 
is rendered the more imperative 
to avoid the presence of disagree- 
able and unsightly objects, as 
well as all causes of excitement, 
and to remove, as soon as possible, 
vivid and unpleasant impressions, 
by quiet diversion of the mind. 

The disastrous results upon the 
foetus of severe injuries received 
by the mother are well known to 
the profession, for premature 
labor and death of the child, or 
feebleness from its prematurity, 
are common results of such acci- 
dents. In rare instances the 
child may be so injured as to be 
deformed for life, as in the fol- 
lowing interesting case : Richard 
L., aged six years, came, in 
January, 1877, to the children's class in the Bureau for the Relief of 
the Out-door Poor. The following history was obtained: On November 
27, 1870, one month before the birth of Richard, the mother fell 
heavily on the ice when stepping from a city car. Uterine hemorrhage 
resulted, which continued more or less freely, producing marked pallor, 




MORTALITY OF EARLY LIFE. 23 

till her confinement, which occurred December 23d. The position of 
the child in utero was crosswise, but nothing untoward occurred in the 
delivery. Immediately after its birth, when it was being washed by 
the nurse, a blister, about one inch in diameter, was observed on the 
right side of the thorax, located about one inch below and two and a 
half inches externally to the nipple. A cicatrix resulted which now 
marks the site of the sore. When the blister healed the child seemed 
entirely well, and nothing more was thought of the unusual occurrence 
of an intrauterine vesication, till nearly half a year had elapsed, when 
the thorax below the nipple and at the site of the cicatrix, was observed 
to be depressed, and the depression has continued to the extent indicated 
in the woodcut. 

The ribs at the point of depression are found to be widely separated ; 
the rib below being pushed downward so as to form one side of the tri- 
angle, its cartilage the second side, and the rib above the hypothenuse. 
The distance of the perpendicular line passing from the costo-chondral 
articulation of the lower rib to the upper rib, or the hypothenuse, is two 
and a half inches by measurement. The depression in this triangular 
space evidently resulted gradually from the wide separation of the ribs, 
and the consequent loss of resiliency in the thoracic walls in the space 
destitute of bony support. The child lay crosswise in utero, and it 
seems probable that the injury was produced by the pressure of its arm 
against the ribs during the fall. Cases like the above, and the graver 
cases in which foetal life is sacrificed, or the child is born to a puny and 
uncertain existence from prematurity, show the very great importance 
of a quiet and regular life on the part of one who is about to become a 
mother ; for bodily injuries, like unpleasant sights, occur when least 
expected. 



CHAPTEE III. 

MORTALITY OF EARLY LIFE: ITS CAUSES AND PREVENTION. 

No fact is better known in the profession than that the first years of 
life constitute the period of greatest mortality. 

In England, where there is an accurate registration of births and 
deaths, statistics show fifteen deaths in every hundred infants in the 
first year of life, and between four and five deaths in the first month. 
Statistics on the continent correspond with those in England, as regards 
the periods of greatest mortality. Quetelet says : .... "There 
die during the first month after birth, four times as many children as 
during the second month after birth, and almost as many during the 
entirety of the two years that follow the first year, although even then 
the mortality is high. The tables of mortality prove, in fact, that one- 
tenth of children born die before the first month has been completed." 



24 MORTALITY OF EARLY LIFE. 

In this country, in consequence of deficient registration of births, the 
percentage of deaths to births cannot be accurately ascertained. In 
this city, 53 per cent, of the total number of deaths occur under the 
age of five years, and 26 per cent, under the age of one year. Accord- 
ing to the census of 1865, there were in New York City 95,020 
children under the age of five years, and during the five years ending 
with 1865, 49,000 children five years old and under had died. There- 
fore, according to these statistics, more than one-third of all the infants 
born in this city die under the age of five years. An error, however, 
occurs from the fact that, while the death statistics were complete, it is 
known there were more children in the city than were embraced in the 
census returns. Still it may, I think, be safely stated that one-fourth 
of the children born in this city die before the age of five years. 

In less crowded cities and the rural districts, it is known that the 
percentage of deaths in the first years of life to the total number of 
deaths is considerably less than in New York City, but it is neverthe- 
less large. 

As the child advances toward puberty, the liability to sickness and 
death gradually diminishes, but even the last years of childhood present 
a considerably larger percentage of deaths to the population than does 
youth or manhood. 

The causes of this great mortality of infants and children, and the 
means of diminishing it, deserve careful consideration. 

Some of the causes which conspire to produce it are to a considerable 
extent unavoidable. Such are congenital vices of formation of internal 
organs. Many of the internal malformations necessarily occasion an 
early death. Cases of anencephalus, most cases of congenital hydro- 
cephalus, of spina bifida, of cyanosis, are fatal before the close of 
infancy. These defects of formation we cannot detect before birth, and 
their causes are often obscure. Some of them seem to result from 
inflammation, believed to be, occasionally, syphilitic, developed at some 
period of foetal existence. Other internal malformations are attributable 
to perturbating influences, operating temporarily on the mother during 
gestation. But in a large proportion of cases, we cannot assign the 
cause. Obviously, only partial success can attend our efforts, as regards 
prevention, in these cases, and almost no success, as regards the use of 
remedial measures. 

Another obvious cause of the great mortality of early life, is natural 
feebleness .of system, especially in infancy. The younger the patient, 
prior to the middle period of life, the sooner are the vital powers ex- 
hausted by disease. Hence a larger proportion of infants succumb to 
the same malady, than children, and a larger proportion of children than 
adults. This statement is true of infancy and childhood in general. It 
is a law in nature, and cannot be changed by art. But there are many 
infants born with hereditary disease, or a strong predisposition to dis- 
ease, through a fault, which is, in a degree, curable, in the system of 
one or both parents ; as, for example, the syphilitic, scrofulous, or tuber- 
cular diathesis.- Parents seriously affected by such diseases cannot, 
without corrective treatment, have healthy offspring. Their children 
are among the first to droop and die, either directly from the inherited 



CAUSES OF INFANTILE MORTALITY. 2o 

disease, or from feebleness of constitution which such disease entails, 
and which renders them an easy £rey to other diseases. The duty of 
the physician, as regards such parents, is obvious. He may, by thera- 
peutic and hygienic measures, secure a more healthy progeny, and, so 
for as he can do this, he aids in diminishing the infantile mortality. 
He may sometimes, by timely measures directed to the infant, establish 
a better state of health. 

The subject of hereditary disease is one of great interest and impor- 
tance, especially as regards the city population. Inherited affections are 
less common in the country, but in the city they contribute largely to 
the number of deaths in early life. 

Another important cause of the great mortality of children, is the fact 
that they are peculiarly liable to certain severe and fatal maladies. I 
allude particularly to the acute infectious diseases, which, as a rule, 
occur but once, and that in childhood. Some of them, as scarlet fever, 
greatly increase the number of deaths. They extend and become 
epidemic through the intercourse of children. We are constantly wit- 
nessing in New York the spread of the acute contagious diseases, 
especially of whooping-cough, measles, scarlet fever, and diphtheria, 
through the schools. Measures employed, thus far, by boards of health, 
or other local authorities, to prevent the dissemination of these and 
kindred diseases, have been but partially successful except in regard to 
smallpox. In the large public schools especially, these maladies are 
most frequently contracted, and from them they radiate over the school 
districts : for if, as is now common, at least in New York City, a child 
comes to school wearing clothes which at home have lain in a room 
where a brother or sister was sick with measles or scarlet fever ; or if 
he enter the class with a mild pertussis or diphtheria, certain of his 
classmates will probably return home infected with the virus of the 
disease. The same remarks are applicable, though with less force, to 
private schools. From both such schools, I have over and over again 
witnessed the dissemination not only of the maladies mentioned, but 
also of the milder infectious diseases, as mumps and varicella. The 
Health Board of New York City have recently, by stringent enactments 
regulating the schools, accomplished much in suppressing this source of 
the infectious diseases. 

In hospitals and asylums for children, much can be done to prevent 
the occurrence of the infectious diseases by strict surveillance and prompt 
isolation of all suspicious cases. Without such care, scarcely a year 
passes in which these institutions are not scourged by one or more of 
these diseases. Much has been said of the crowding of families in tene- 
ment-houses, so common in New York and other large cities, by which 
a large number of children are brought under one roof; of the un clean- 
liness of person and apartment to which it leads, and of the insufficient 
air and space which it allows to each. But one of the strongest 
objections, in my opinion, to the present plan of building and crowding 
tenement-houses is the facility which it affords for the spread of the con- 
tagious diseases of childhood; and it is in such houses, as shown by 
statistics, that these maladies are the most frequent and fatal. The 
much-needed enactments or regulations in relation to the construction 



26 MORTALITY OF EARLY LIFE. 

and occupancy of such houses, would, among other salutary effects, 
greatly diminish the death-rate from the infectious maladies. 

Over the most loathsome, and formerly the most fatal, malady of man- 
kind, namely, smallpox, we now have, or can have, complete control by 
statutory enactments enforcing vaccination. It is only by carelessness 
or the lack of sufficiently stringent regulations relating to the matter 
that smallpox is not ''stamped out." Again, some of the most fatal 
inflammatory diseases of life occur chiefly in childhood, as croup and 
capillary bronchitis. These and kindred diseases can only be pre- 
vented by proper hygienic management on the part of families, and the 
circulation of tracts, or other means calculated to educate families in 
reference to the management of children, cannot fail to diminish the 
number of cases of such inflammations, and, consequently, of the deaths 
from them. 

Another obvious and important cause of the mortality of early life, is 
the antihygienic condition or state in which many children live, in con- 
sequence of the poverty or gross negligence of parents. 

Residence in insalubrious localities, personal and domiciliary unclean- 
liness, exposure without proper protection to vicissitudes of weather, are 
fertile causes of sickness and death. Hence one reason for the great in- 
fantile mortality among the city poor, who live in damp and dark alleys, 
and in crowded and filthy tenement-houses, breathing night and day an 
atmosphere loaded with noxious gases. All physicians are aware how 
the most fatal diseases, such as Asiatic cholera, cholera infantum, diph- 
theria, and typhus fever, seek the quarters of the city poor, and what 
terrible havoc they make there. All are aware, also, what wonderful 
recoveries result, when feeble and attenuated infants, gradually sinking 
with chronic diseases, induced in great measure by the foul air, are 
transferred from such localities to the pure air of the country. 

Careless management of young children as regards dress increases 
greatly the liability to local diseases, such as commonly occur from ex- 
posure to cold. These are inflammatory affections, seated chiefly upon 
the mucous surfaces, but sometimes in parenchymatous organs. Adults, 
aware of the effect of sudden change of temperature from warm to cold, 
or of exposure to currents of air, protect themselves by additional cloth- 
ing. Such precautionary measures are often lacking in the management 
of young children, and hence one cause of their great liability to local 
affections, both of the respiratory and digestive organs. 

Routh, in his excellent treatise on Infant Feeding, says : " Among 
the most pernicious influences to young children, however, we may 
include cold ; the change of temperature from 45° to 4° or 5° below 
zero, as before stated, producing an increase of mortality in London 
alone of three to five hundred. As out of one hundred deaths, how- 
ever, from all specified causes, nearly twenty-four occur to children 
under one, and thirty-six to children under five, the great increase of 
mortality to children by cold is thus at once made obvious. Indeed, it 
is a household word among us, which takes its origin from the Registrar- 
General's returns, that a very cold week always increases the mortality 
of the very young and the very aged." 

Lastly, a very important cause of mortality in early life is the use of 



LOCALITIES AXI) CLEAXLIXESS. 27 

improper food. In infants, artificial feeding in place of the aliment 
which nature has provided for them, and, in children, the use of in- 
nutritious or indigestible articles of diet, give rise to diarrhoeal mala- 
dies, emaciation, and death in numerous instances. Sometimes, also, 
defective alimentation is the cause of scrofulous or tuberculous ailments, 
.and sometimes it gives rise to a cachexia or feebleness of system, which, 
without engendering any positive disease, renders those thus affected 
less able to support disease induced by other causes. A committee, of 
which Professor Austin Flint, Jr., was chairman, appointed in 1867 
to revise the " dietary table of the Children's Nurseries on Randall's 
Island," states, with much truth and force : "Children . . . are 
not capable of resisting bad alimentation, either as regards quantity, 
quality, or variety. At that age the demands of the system for nourish- 
ment are in excess of the waste ; the extra quantity being required for 
growth and development. If the proper quantity and variety of food 
he not provided, full development cannot take place, and the children 
grow up, if they survive, into puny men and women, incapable of the 
ordinary amount of labor, and liable to diseases of various kinds." 

Improper feeding, like other causes of mortality, is much more in- 
jurious, much more frequently the cause of death, in the city than in 
the country. Statistics in Europe, as well as this side of the Atlantic, 
establish this fact. It is in infancy, and especially in the first year, 
that the use of unwholesome food entails the most serious consequences. 
No artificially prepared food is a good substitute for the mother's milk, 
and hence artificial feeding of the infant, unless under the most favor- 
able circumstances, results disastrously. In the country, where salu- 
brious air and sunlight conspire to invigorate the system, where a robust 
constitution is inherited, and where cow's milk, fresh and of the best 
quality, is readily obtained, lactation is not so necessary for the well- 
being of the infant ; but in the city, its importance cannot be too 
strongly urged. 

The foundlings of cities afford the most striking and convincing 
proof of the advantages of lactation. In some cities foundlings are 
wet-nursed, while in others they are dry-nursed, and the result is 
always greatly in favor of the former. Thus, on the Continent, in 
Lyons and Parthenay, where foundlings are wet-nursed almost from 
the time that they are received, the deaths are 33.7 and 35 per cent. 
On the other hand, in Paris, Rhehns, and Aix, where the foundlings 
were whollv dry-nursed, at the date of the statistics their deaths were 
50.3, 63.9, and 80 per cent. 

In this city the foundlings, amounting to several hundred a year, 
were formerly dry-nursed ; and, incredible as it may appear, their 
mortality with this mode of alimentation, nearly reached 100 per cent. 
Now wet-nurses are employed for a portion of the foundlings, with a 
much more favorable result. 

These facts, to which others might be added from the experience of 
European cities, show the importance of lactation as a means of reducing 
infantile mortality in the cities. What has been stated as regards the 
result of artificial feeding of foundlings, is true, in great measure, in 
reference to all city infants. The ill-effect of artificial feeding is well 



28 Weight, growth, lactation. 

known in this city, and it is the common practice in families to employ 
a hired wet-nurse, if, for any reason, the mother's milk is insufficient. 

When the infant has reached the age at which it is proper to wean, 
the digestive organs are less frequently deranged by errors of diet. 
More substantial food, and considerable variety in it, may now be not 
only safely allowed, but are required by the wants of the system. 
In infancy, therefore, the mortality is largely increased by improper 
diet, while in childhood the diet is a much less common cause of death. 



CHAPTEE IV. 

WEIGHT, GROWTH, LACTATION. 

Dr. K. Parker, Resident Physician of the New York Infant 
Asylum, weighed, immediately after birth, 170 infants — 89 male and 
81 female — born consecutively, and at term, with the following result : 

Average male weight 7 lbs. 11 oz. 

" female ' c . . . . . 7 " 4 " 

Fifty of these, who were wet-nursed, and apparently well taken care 
of, were weighed when one week old, with the following result: 

Increase of weight in . . . . . . . .32 cases. 

Loss of weight in . . . . . . . . 13 " 

Average gain . ■ 4 T \ oz. 

" loss H " 

Greatest gain 12 " 

" loss 6 " 



AVERAGE GAIN". 




'rom birth to age of 4 months (25 cases) . 
" 3 to 6 months (6 cases) .... 
" 6 to 9 " " .... 
" 9 to 12 " " .... 


, 4 lbs. 8| 

. 3 " 3£ 

. 2 « 7* 

1 « 15£ 



It is desirable that the infant, as soon as it requires nutriment, should 
receive breast-milk. If it be fed for a few days with the bottle or spoon, 
it may be difficult finally to induce it to take the breast; therefore it is 
well to determine early whether the mother will be able to wet-nurse 
her infant, so that, if unable, suitable provision may be made. 

The matter of determining beforehand the capability of the mother 
for wet-nursing has been investigated by Dr. Donne, of Paris, and in 
his treatise on Mothers and Infants, he describes the mode in which it 
may be ascertained. The desired information, in his opinion, may be 
acquired by examining the colostrum, which is secreted in small quan- 



HINDRANCES TO LACTATION. 29 

tity, in the last months of gestation, and which can be squeezed from 
the breast in sufficient quantity for inspection. 

In some women, according to Dr. Donne, the colostrum is so scanty 
that only a drop, or half a drop, can be obtained from the nipple by 
careful pressure. This will be found by the microscope to contain but 
few milk-globules, ill-formed, and a few granular bodies, such as the 
colostrum ordinarily contains. Such women almost invariably furnish 
poor milk, and in small quantity. In other women the colostrum is 
abundant but thin, resembling gum-water; it lacks the yellow streaks 
and viscous character of ordinary colostrum, and it flows readily from 
the nipple. The milk of such women is sometimes scanty, sometimes 
abundant, but it is watery and deficient in nutritive principles. In a 
third class of women the colostrum is pretty abundant, and it contains 
yellowish streaks, of more or less consistence, which are found to be 
rich in milk-globules of good size. Women furnishing such colostrum 
in the last weeks of gestation will have sufficient milk and of good 
quality. These latter women make the best wet-nurses. 



Hindrances to Lactation and Physical Conditions Rendering- it 

Improper. 

The primipara often experiences difficult}^ in wet-nursing in conse- 
quence of a depressed state of the nipple. It is not sufficiently jDromi- 
nent to be readily grasped by the mouth, and after ineffectual attempts, 
the infant becomes fretful when applied to the breast, and perhaps for 
a time refuses it altogether. Multipara occasionally experience the 
same inconvenience, but it is not common when there has once been 
successful lactation. By calmness and perseverance on the part of the 
mother, the nursling can usually be made to seize the nipple in the 
course of a week. 

Depression of the nipple is, to a certain extent, the result of pressure 
upon it by the dress during gestation. The state of the nipples should, 
indeed, in those who have never suckled, receive early attention, even' 
before the birth of the infant. Tightness of dress around the breast, 
as also upon every part of the body, should be avoided, and from time 
to time gentle traction should be made upon the nipple, if it be de- 
pressed. It may be drawn out by the fingers of the mother several 
times each day, or by a common breast-pump, or by suction with a 
tobacco pipe, the edge of the bowl having been smoothed. Occasionally, 
in these cases of depressed nipple, the mother, fatigued and discouraged 
by her frequent ineffectual attempts to induce the infant to nurse, 
becomes feverish and excited, so that the quantity of her milk is sen- 
sibly diminished. The physician should assure her, as he usually can 
with confidence, that in a few days, as the baby becomes a little stronger, 
there will be no difficulty in its nursing. Some women are unremitting 
in their endeavors to procure nursing. This should be forbidden, since 
the lack of sleep, and the nervousness which such constant endeavor 
produces, tend to defeat the object which they have in view, by dimin- 
ishing the secretion of milk. Sufficient sleep, freedom from anxiety, 



30 WEIGHT, GROWTH, LACTATION. 

and no more frequent application of the infant to the breast than is 
required in successful lactation should he enjoined. Occasionally we 
can best succeed in procuring lactation under these circumstances of 
discouragement by the aid of another infant, older, more vigorous, and 
better able to seize the nipple. An exchange of infants for a few times 
may remedy the difficulty. 

Occasionally suckling is rendered difficult and painful by too long 
delay before applying the infant to the breast. When the mother has 
rested a few hours after her confinement, about six in ordinary cases, 
lactation may commence. There is, at first, but very little milk, often 
only a few drops, but the secretion is promoted by nursing, so that the 
requisite amount is sooner obtained than when the infant is kept from 
the breast till the second or third day. If, as some physicians advise, 
suckling be deferred till the breasts are full and tender, and if, as is 
often the case with primiparae, the nipples are also tender, many mothers 
lack the fortitude required to allow their infants to obtain a sufficient 
amount of milk. Excoriated and fissured nipples constitute a serious 
impediment to lactation. They are very sensitive on pressure, and are 
long in healing. They are fully described in works which relate to 
female diseases, and their treatment pointed out. Occasionally fissured 
nipples do harm to the infant by the blood which escapes and is swal- 
lowed with the milk. A case is related in which positive indigestion 
was caused in this way ; the infant vomiting, after each nursing, milk 
mixed with blood. The local hindrances to lactation described above 
can, in most instances, be relieved in the course of a few weeks. To 
what extent menstruation and pregnancy are detrimental to the nursing, 
and, therefore, contraindicate lactation, will be considered in another 
section. 

There is, occasionally, a constitutional state of the mother which 
necessitates either the employment of a hired wet-nurse or weaning. 
This is the case when there is a strong tendency to tuberculosis. If 
the complexion be pallid, the system at all emaciated, and suckling be 
attended by more or less exhaustion, and if with fair trial of wine and 
tonics no improvement follow, the physician is justified in forbidding 
further attempts at wet-nursing. If, under such circumstances, an 
hereditary tendency to tuberculosis exist, it is his duty positively to in- 
terdict nursing. The opinion of the physician, in such a matter, should 
be formed after mature deliberation. There are many women who, 
suffering temporarily from illness, and discouraged, are ready at once 
to abandon their infants to the care of others, with the least encourage- 
ment on the part of the physician to do so, but who, by attention to 
their own health, and especially by taking more sleep, soon recover 
from their depression, and become good wet-nurses. On the other 
hand, night-sweats, a cough, and progressive decline in health, show 
the need of immediate suspension of wet-nursing. 

Sometimes women, prior to pregnancy, present indubitable evidence 
of tuberculosis, but by the improved general health which attends preg- 
nancy, the disease is temporarily arrested. Such women should never 
suckle their infants. If they do, they soon lose all that was gained, 
and the disease advances rapidly. These objections to wet-nursing in 



HINDRANCES TO LACTATION. 31 

such a state of health apply to the mother. There are also objections 
as regards the infant. The milk of those in decidedly infirm health 
is deficient in nutritive principles. Their infants, therefore, are ill- 
nourished, and, if they have inherited a predisposition to tuberculosis, 
there is great danger that this disease will be developed in them ; 
whereas, with healthy wet-nursing, even a strong predisposition may 
remain latent. M. Donne relates the following instructive cases, which 
show the danger which sometimes attends suckling, and the imperative 
necessity which may arise of discontinuing it. U A very light-com- 
plexioned young mother, in very good health, and of a good constitu- 
tion, though somewhat delicate, was nursing for the third time, and, as 
regarded the child, successfully. All at once this young woman expe- 
rienced a feeling of exhaustion. Her skin became constantly hot ; there 
were cough, oppression, night-sweats; her strength visibly declined, and 
in less than a fortnight she presented the ordinary symptoms of con- 
sumption. The nursing was immediately abandoned, and from the 
moment the secretion of milk had ceased, all the troubles disappeared." 
" A woman of forty years of age . . . having lost, one after another, 
several children, all of whom she had put out to nurse, determined to 
nurse the last one herself. . . . This woman, being vigorous and 
well built, was eager for the w r ork, and, filled with devotion and spirit, 
she gave herself up to the nursing of her child with a sort of fury. At 
nine months she still nursed him from fifteen to twenty times a day. 
Having become extremely emaciated, she fell all at once into a state of 
weakness, from which nothing could raise her, and two days after the 
poor woman died of exhaustion." 

A very similar case recently occurred in my practice. A young 
and healthy woman from the country, suckling her second infant, on 
coming to the city lived in a dark and very imperfectly ventilated 
room on the first floor, and in the rear of a crowded tenement-house. 
She soon lost her appetite, but continued suckling for three months, 
when she became so anemic and feeble that she was compelled to seek 
medical advice. She died without local disease, notwithstanding the 
most nutritious diet and free use of stimulants and tonics. 

Constitutional syphilis in the mother does not contraindicate lacta- 
tion. It is probable that the infant also has it. The mother should 
take anti-syphilitic remedies, which will eradicate the disease in herself, 
and also, if it be present, in the infant. Febrile affections, also, do not 
in general contraindicate lactation. They may, however, for a time, 
diminish the quantity of milk or impair its quality. If, however, the 
mother be in a critical state, or much reduced, whatever the disease, 
suckling should cease. Whether or not the infant should be taken 
from the breast, if the mother be suffering from one of the essential 
fevers, depends on the severity of the malady, and the degree of her 
exhaustion. Twice I have known newly born infants to be suckled by 
mothers, while the latter had scarlet fever, without contracting it, but 
suffering immediately afterward from protracted and severe eczema. In 
the country, wmere artificially fed infants, as a rule, do well, it might be 
best to wean if the mother be affected with such a disease, but in the 
city eczema is less dangerous than the diarrhoeal affections wdiich early 



62 WEIGHT, GROWTH, LATATION. 

weaning is apt to entail. In most cases of typhus and typhoid fevers, 
weaning or procuring a wet-nurse is necessary, on account of the de- 
pression of the vital powers, which these diseases produce. 

Inflammatory affections, unless of a dangerous character, do not ordi- 
narily interfere with lactation, except that the quantity of milk is 
somewhat diminished. In severe inflammation, it may be so necessary 
to husband the strength, or to keep the patient perfectly quiet, that 
suckling her infant would be injudicious. It should then be transferred 
to a wet-nurse or weaned. Inflammation of the breast often presents 
an impediment to lactation. It is a common and painful affection, 
suspending or greatly diminishing the secretion of milk in the affected 
gland. Nursing should cease as soon as there are evident signs of in- 
flammation, unless it be limited to a small part of the gland. General 
heat of the breast, with tenderness and induration extending over a 
considerable part of it, indicates the need of the immediate removal of 
the infant from it. Lactation must be restricted to the unaffected side. 
It is often the case that the volume of the inflamed gland is consider- 
ably increased from the afflux of blood to it, and from the interstitial 
exudation, while it contains little or no milk, and attempts at lactation, 
under such circumstances, are injurious to the mother as well as to the 
infant. The cause of the swelling should be explained to the mother, 
who commonly attributes it to the accumulation of milk, and worries 
herself and the infant by attempts to make it nurse. As the inflam- 
mation abates, by resolution, or more commonly by suppuration, and 
the normal secretion returns, the first milk, which is apt to be thick 
and stringy, should be rejected, after which the infant may nurse as 
usual. Occasionally, the abscess which has formed in the breast con- 
nects with a lactiferous tube, so that pus may, on suction, escape from 
the nipple. If this occur, of course lactation should be interdicted until 
pure milk is obtained. Pus in the milk can sometimes be detected by 
the naked eye. It presents a yellowish or greenish color, occurring in 
streaks when not intimately mixed with the milk. When it is inti- 
mately mixed, and in small quantity, it cannot be detected by the 
naked eye, but the microscope reveals the pus-globules. M. Donne 
relates a case in which he discovered these globules by the microscope, 
although there were at first no other evidences of an abscess, and doubts 
were expressed in reference to the accuracy of his observation. Finally, 
an abscess pointed and discharged. 

Sometimes, when the inflammation abates, the secretion does not 
return, and, worse still, occasionally the inflammation has occurred so 
near the nipple that the lactiferous tubes are permanently closed by it. 
so that, though milk form in the breast, there is no escape for it. 
Thenceforth lactation must be entirely from one breast. 

If erysipelas occur in the mother, the infant should be immediately 
taken from her breast and from her arms. If this disease should not 
be communicated to the infant through the milk, or through fissures in 
the nipple, of which there is danger, still the milk is apt to undergo 
such change in consequence of the erysipelas as to endanger the health 
of the child. Thus, one of the wet-nurses in the New York Infant 
Asylum sickened with severe facial erysipelas on the 24th of April, 



COLOSTRUM. 33 

18T5, eight days after the death of her baby. She was wet-nursing a 
foundling, a°;ed seven weeks, at the time of the commencement of the 
erysipelas, and as it was very important that her milk should be pre- 
served for the coming hot months, it was deemed best to allow the 
nursing to continue, the infant being placed in a crib at a little distance 
as soon as it dropped the nipple. On the 27th, the baby was troubled 
with diarrhoea. April 28th, its morning temperature was 101°, and 
that of the evening 103°, the diarrhoea continuing. It was now removed 
entirely from the breast, and was given artificial food. On the 29th 
there was a decided general icteric hue of the infant's surface, which 
continued till its death on May 1st. The stools numbered about eight 
daily till April 30th, when they ceased. The record which I preserved 
does not state whether there was vomiting, but it had probably been 
slight on account of the speedy prostration. Death occurred from ex- 
haustion. At the autopsy, from half an ounce to one ounce of pus 
was found in the peritoneal cavity, newly formed fibrin was observed 
upon the spleen and liver, and the peritoneum generally had lost much 
of its lustre; a careful microscopic examination of the liver and its 
ducts, made by Dr. Heitzmann, revealed no anatomical change which 
would explain the icteric hue, and it seemed probable that this was due 
to the altered state of the blood. The mucous membrane of the intes- 
tines exhibited vascular streaks, and its follicles were distinct. The 
lesions, therefore, indicated intestinal catarrh. Nothing unusual was 
observed in the heart and lungs of the infant. Its life had apparently 
been sacrificed by the unhealthy nursing. 



Colostrum. 

The milk secreted during gestation, and immediately after the birth 
of the infant, differs in its gross appearance, as well as chemical and 
microscopical characters, from that which is ordinarily secreted during 
lactation. It is termed Colostrum. It has a turbid and yellowish 
appearance, and is somewhat viscid. It is decidedly alkaline, and 
undergoes lactic acid fermentation more readily than common milk, and 
it also contains more solid matter. It has an excess of fat, of salts, 
and, according to Simon, also of sugar. It appears, from Simon's 
analysis, that the solid matter of colostrum is about IT per cent., while 
that of the ordinary breast-milk is about 11 per cent. 

Examined by the microscope, the colostrum is seen to contain oil- 
globules and a viscid substance, which often assumes an ovoid or globular 
form, but which also exists in irregular masses of considerable size. 
This substance has been thought by some to be mucus, but it is dis- 
solved by acetic acid and potash, and is tinged yellow by a watery 
solution of iodide. It is therefore to be regarded as albuminous. Em- 
bedded in this substance are oil-globules, which are for the most part of 
small size, while the free oil-globules of colostrum are larger than those 
occurring in healthy milk. This viscid substance, with the imprisoned 
oil -globules, constitutes what has been designated the "colostrum-cor- 
puscles. ' ' Some have erroneously considered the ' ' colostrum-corpuscles ' ' 

3 



31 



AVEIGHT, GROWTH, LACTATION. 



to be compound granular cells. The compound granular cell, or cor- 
puscle, is a cell which has undergone fatty degeneration. It is distended 
with oil-globules to perhaps twice or thrice its normal size. On the 
other hand, examination of the "colostrum-corpuscles" fails to detect 
a cell-wall, and the large and irregular size of some of these corpuscles 
negatives the idea that they are cells. The oil-globules contained in 
the viscid substance are more readily acted on by ether than are the 
free oil-globules. 

The colostrum is replaced by milk of the normal character in six to 
eight days ; sometimes as early as the third or fourth day after delivery. 



Fig. 2. 



n Go OO 
o O ° 

















3Iilk-globules. 



Colostrum-corpuscles . 



In exceptional instances the colostrum does not disappear for several 
weeks, and it may reappear at any time during lactation, as a conse- 
quence of derangement of the system, or from disease. It is assimilated 
with difficulty by the digestive organs of the infant, producing usually 
a laxative effect. It, therefore, aids in the removal of the meconium, 
and, being a normal secretion in the first week of lactation, it is to be 
regarded as beneficial. Continuing longer than the first week, its effect 
is deleterious. It produces evident derangement of the digestive organs, 
and the infant that habitually nurses it never thrives. It has diarrhoea 
or vomiting, becomes more or less emaciated, and suffers from colicky 
pains. Sometimes an extreme degree of exhaustion is reached before 
the cause is suspected, for, if the milk be pretty abundant, the admix- 
ture of colostrum with it cannot be detected by the naked eye. The 
microscope alone reveals it. The following is an interesting example 
of this fact. In 1868, an infant six weeks old was brought to me, 
with the following history: The mother had for several years been 
troubled with dyspeptic symptoms, but had otherwise been in good 
health. The infant at birth was fleshy and strong, but after the first 
week it had never thrived like other infants. It nursed regularly, and 
the quantity of milk was apparently sufficient, but it vomited as soon 
as it ceased nursing; it w T as much emaciated, and the bowels were 
habitually constipated. The digestive organs of the infant had been in 
this unhealthy state, with little variation, from the first week, and it 
was very evident, from the emaciation and exhaustion, that it must soon 
perish unless some change w T ere effected. The milk of the mother 
presented the usual appearance to the naked eye, but under the micro- 
scope colostrum-corpuscles were observed. A wet-nurse was immediately 



HUM AX MILK 



35 



obtained, and from that moment the gastrointestinal symptoms disap- 
peared, with a rapid recovery. This case shows at once the evil effects 
of the colostrum, and the need of a microscopic examination of the milk 
whenever the nursling suffers from lactation. 



Human Milk. 

The specific gravity of human milk is about 1032. It has been care- 
fully analyzed by different chemists, with nearly the same result. The 
following table, prepared by MM. Vernois and Becquerel, gives the pro- 
portion of the various ingredients in 1000 parts : 

Water 889.08 

Sugar 43.64 

Casein and extractive ........ 39.24 

Butter , . . . 26.66 

Salts (ash) . ■ 1.38 



1000.00 



Recently Prof. Albert R. Leeds has analyzed forty-three samples of 
healthy human milk, with the following results : 





Average. 


Minimum. 


Maximum. 


Specific gravity 


. 1 0317 


1.030 


1.0353 


Water . 


. 86.766 


83.34 


89.09 


Total solids . 


. 13.234 


10.91 


16.66 


Total solids not fa 


t . . 9221 


6.57 


12.09 


Fat 


. 4.013 


2.11 


6.89 


Milk-sugar . 


. 6.997 


5.40 


7.92 


Albuminoids 


. 2.058 


0.85 


4.86 


Ash 


. 0.21 


0.13 


0.35 



It is seen that the constituents of healthy human milk vary consid- 
erably in different women, especially the albuminoids, which are the 
nutritive part. Leeds found all the samples alkaline except one, which 
was neutral. The heat-producing constituents, the carbohydrates, fat, 
and sugar vary less than the albuminoids. Although human milk 
seems thinner than cow's milk, it nevertheless contains more solids and 
less water, and has a greater specific gravity. Milk sugar is its largest 
solid constituent. Both the sugar and the fat are in greater proportion 
than in cow's milk, while the amount of albuminoids is much less. A 
very important difference between woman's milk and cow's milk is in 
the casein, not only in the quality, but quantity. The casein of cow's 
milk coagulates in large, firm masses, digested with difficulty by the 
infant, and its quantity is nearly five times greater than that in human 
milk, as we see by the following analysis of Prof. Leeds. Leeds found 
the average specific gravity of cow's milk 1029. 





Woman'' & Milk. 




Cow's Milk. 




Mean. 


Minimum. 


Maximum. 


Mean. 


Minimum. 


Maximum 


Water . 


87.09 


83.69 


90 90 


87.41 


80.32 


91.50 


Total solids 


12 91 


9.10 


16.31 


12.59 


8.50 


19 68 


Fat 


3 90 


1.71 


7.60 


3.66 


1.15 


7 09 


Milk-sugar 


6.04 


4.11 


7.80 


4.92 


3.20 


5.67 


Casein 


0.63 


0.18 


1.90 


301 


1.17 


7.40 


Albumen 


1.81 


0.39 


2.35 


0.75 


0.21 


5.04 


Albuminoids 


1.94 


0.57 


4.25 


3.76 


1.38 


12.44 


Ash 


0.49 


0.14 


? 


0.70 


0.50 


0.87 



36 WEIGHT, GKOWTH, LACTATIOX. 

Milk, being the sole food of early infancy, contains all the nutritive 
principles which are required for the growth and repair of the different 
tissues. Most of the salts which occur in the tissues exist primarily 
in the milk. Phosphate of lime, phosphate of magnesium, phosphate 
of the peroxide of iron, chloride of potassium, and chloride of sodium, 
known to exist in cow's milk, are believed to occur also in human milk. 
Epithelial cells are sometimes present, derived from the lining mem- 
brane of the lactiferous tubes. 



Modification of Milk in Consequence of tfce Diet. 

The relative proportion of the different ingredients of the milk varies 
according to the diet. If the diet be poor, the amount of water increases, 
and that of butter and casein diminishes. Lehmann says(P%s. Chem- 
istry ■, vol. ii. p. 65) : " From experiments made on bitches, it would 
appear that a vegetable diet renders the milk richer in butter and 
suo-ar ; while the solid constituents are augmented when a sufficient 
quantity of mixed food is given. Peligot found the milk of an ass most 
rich in casein when the animal had been fed on beet-root ; while it was 
richest in butter when the food had consisted of oats and lucerne. Fat 
food increases the quantity of the butter. Boussingault found the milk 
of a cow richer in casein when the animal had been fed on potatoes than 
when other food was taken. Reiset found that the milk of cows which 
were at grass was much richer in butter than when the animals had 
stood all night in their stall without food ; but Play fair found, on the 
contrary, that the quantity of butter in the milk increased during the 
night as much as during their stall-feeding, but that the quantity of 
butter in the milk was considerably diminished by the motion of the 
animals in the fields." 1 Simon made the following analyses of the milk 
of a poor woman. She was suddenly, during the period of lactation, 
deprived of the means of support, so that her food was insufficient in 
quantity, and of poor quality. The amount of her milk was not dimin- 
ished by privation, but the solid constituents were reduced to 86 parts 
in 1000. After this, for a time, her diet was nutritious and abundant, 
the quantity of milk was increased, and the solid constituents amounted 
to 119 parts in 1000. Her diet was again reduced, with a reduction 
of the solid elements to 98 in 1000, and, at a later period, the diet was 
again nutritious, with an increase of the solid elements to 126. The 
chief variation observed in the milk of this woman was in the amount 
of butter. 



Modification of Milk from its Retention in the Breast. 

M. Peligot has clearly demonstrated that the longer milk is retained 
in the breast the more watery it becomes. This is explained on the 
supposition that the solid portion is first absorbed. Therefore, the 
milk is richer the more frequently it is removed from the breast. A 

1 Animal Cbem., Sydenham Soc.'s Tran., vol. ii. p. 55. 



MODIFICATION OF MILK BY AGE. 37 

similar fact, which has the same explanation, has long been known, 
namely, that the first milk taken from the breast is thinnest, while that 
which flows last is richest. That first removed has remained longest in 
the gland, while that which comes last is but recently secreted. 

A knowledge of this fact is of considerable practical importance. 
The milk, as M. Donne has shown, may be too rich, so as to cause in- 
digestion, with more or less enteralgia, in the infant. Some nurslings, 
if the milk be too rich and abundant, reject a part of it by vomiting, 
but others do not, and suffer the consequence in derangement of the 
digestive organs. For such cases the remedy is, to give the breast less 
frequently, by which a less amount of milk is taken, and milk of a 
poorer quality. On the other hand, if there be poverty of the milk, 
and the infant be insufficiently nourished, the milk is more nutritious, 
if the nursing be at short intervals. 



Modification of Milk by Age and by Mental Impressions. 

The composition of milk varies, also, according to the age of the 
infant. Simon analyzed the milk of a woman at intervals for the period 
of about six months. In this case the amount of casein at first was 
small, but the quantity increased during the two months succeeding de- 
livery, after which it was nearly stationary. A similar increase was 
observed in reference to the saline substances. The sugar, on the other 
hand, diminished in quantity as the infant grew older, its maximum 
amount being in the first and second months. The quantity of butter 
in the milk varies from day to day more than the other elements. 

Many observations have been published which show that the composi- 
tion of the milk may be materially changed by mental impressions. The 
infant has died suddenly in the act of nursing, after his mother had been 
violently excited. Such a case is related by Tourtnal. The infant 
ceased nursing, gasped, and died in the mother's lap. In other cases 
convulsions have occurred. MM. Becquerel and Vernois made the chemi- 
cal analysis of the milk of a woman in a state of nervous excitement, and 
found that the solid constituents were diminished to 91 parts in 1000, 
the most marked diminution being in the butter, wdiich was only about 
5 parts. In a case related by Parmentier and Deyeux the milk became 
watery and viscid, and remained so till the nervous attacks, from which 
the patient suffered, had ceased. Dairymen are well aware how ill- 
treatment and the separation of the calf from the cow diminish the 
milk which she yields. A new milkman seldom obtains as much milk 
as one with whom the cow r is familiar. Bouchut, alluding to the influ- 
ence of the moral affections on the secretion of milk, makes the follow- 
ing remark, the truth of which most mothers will acknowledge : "It is 
also a fact, that the sight of the nursling, the idea of seeing it at the 
breast, and the joy which certain mothers thence experience, exercise a 
moral influence over the secretion of the milk entirely independent of 
their will. They feel the draught of milk as soon as they behold their 
child, or think of it too deeply ; and in a woman who saw her child fall 
to the ground, the flow of milk ceased, and did not reappear until tho 
child, having quite recovered, attempted to take the breast." 



38 • WEIGHT, GROWTH, LACTATION. 



Modification of Milk by the Catamenial Function, Pregnancy, 
and Other Causes. 

The catamenia reappear in most women before the close of lactation, 
often by the fifth or sixth month after delivery. If this function be re- 
established in the normal manner — that is, without any derangement of 
the system, without pain or undue profuseness — no unfavorable result 
ordinarily occurs with the infant. On the other hand, if the mother 
suffer any disturbance of the system, or if the menses be profuse, the 
lacteal secretion may be so changed that the infant is injuriously affected 
by it. The symptoms produced are those of indigestion, such as abdom- 
inal pains, more or less vomiting, and diarrhoea. This result is, how- 
ever, in my experience, quite exceptional. In rare instances, more 
dangerous symptoms occur in the infant. A case has been reported to 
me in which, at each catamenial period, the nursling was seized with 
convulsions. 

Charles Marchand found in three chemical analyses of the milk 
during menstruation, a diminution of two to four parts in the butter, of 
two to five parts in the sugar, and a diminution in the casein and 
albumen of two to five parts. This seems but a trifling change when 
we recollect that human milk in the state of health contains, according 
to the analysis of M. Robin and others, 25 to 37 parts of butter, 37 to 
49 parts of sugar, and 29 to 39 parts of casein, in 1000 of milk. If the 
menses reappear with regularity, when the infant has attained the age 
of ten or twelve months, they should be considered as designed to 
supersede the secretion of milk, which, indeed, usually begins to 
diminish. Weaning is then proper. If the menses return early in the 
period of lactation, and give rise to symptoms in the infant in conse- 
quence of the altered quality of the milk, it is best to allow but little 
nursing during the catamenia, and to employ artificial feeding instead, 
until the flow of blood ceases. 

The change produced in the milk by pregnancy is, in general, more 
injurious to the nursling than that caused by the reappearance of the 
menses. The milk of the pregnant woman frequently contains more or 
less of the viscid substance which characterizes colostrum. Still, the 
milk of pregnancy does not, ordinarily, derange the digestive function as 
much as colostrum, in the first weeks of lactation, for pregnancy rarely 
occurs till after the infant is five or six months old, when the organs 
of digestion are less readily disturbed. The injurious effect of preg- 
nancy on the infant is shown by vomiting or diarrhoea, by restlessness 
and occasional abdominal pains, — in fine, by symptoms of indigestion. 
In many cases, however, these symptoms do not occur, and the infant, 
though nursing regularly, continues to thrive. No doubt, as a rule, the 
nursling should be weaned when there are clear evidences of pregnancy, 
but, under certain circumstances, weaning is injudicious. I have, on 
diiferent occasions, been called to infants, in midsummer, dangerously 
sick with diarrhoeal attacks induced by this cause. These infants were, 
perhaps, doing well, or suffering but little from indigestion, when the 
mothers, suspecting themselves pregnant, at once withdrew them from 



DIFFEKENCES IN SUCKLING WOMEN. 39 

the breast, and cholera infantum or a kindred disease was the result. 
No infant in the city should be weaned in the hot months. It is much 
safer, though there be indubitable signs of pregnancy, that it continue 
nursing till the cold weather. The better method is, however, under 
such circumstances, to employ a wet-nurse, or to remove the infant to 
the country, and wean it there. In cold weather, it is usually safe to 
wean an infant in the city after it has reached the age of five or six 
months. 

Sometimes a young mother devotes herself unremittingly to the care 
of her infant, giving it the breast every hour or oftener through the 
day, and frequently through the night. She gives the infant little rest 
and has but little herself. This devotion, praiseworthy as it is, is 
nevertheless very injurious to both parties concerned. The rule should 
be repeated and remembered, that while an infant may nurse hourly 
during the first month, except in the hours which the mother requires 
for sleep, in which it should not nurse more than once or twice, after 
the first month nursing should be restricted to intervals of two hours 
till the third or fourth month; and in older infants, with greater capa- 
city of the stomach, to intervals of three or four hours. Too frequent 
nursing produces indigestion with its usual fretfulness, and diarrhoea, 
and it deprives the mother of the mental composure and rest which are 
required for successful lactation, but the more the infant frets, in many 
instances, the oftener the mother applies it to the breast, which only 
increases the indigestion. Worriment and lack of sleep tend not only to 
diminish the milk, but also to impair its quality. 

Venereal excesses have a very injurious effect on the character of the 
milk. In our remarks on the hygienic treatment of the summer diar- 
rhoea of infants, we allude to authenticated cases in which excesses of 
this kind caused fatal intestinal catarrh in the nurslings. Again, the 
relative proportion of the ingredients in the milk may habitually vary 
from the normal without any assignable cause, so as to be injurious to 
the infant. Habitual ill-health, as from phthisis, anaemia, syphilis, or 
severe nervous disorder, sometimes so affects the secretion of milk, as 
to render it unsuitable for the infant. It may cause a reappearance of 
the colostrum, like that immediately after parturition. Medicinal sub- 
stances also sometimes occur in the milk, among which may be men- 
tioned the ethereal oils, iron, iodide of potassium, arsenic, zinc, mercury, 
the salines, bismuth, lead, antimony, rendering it unsuitable for lactation. 
It is a well-known fact, that the peculiar flavor of certain vegetables, 
taken as food, may be noticed in the milk. It is admitted, also, that 
the specific virus of the contagious diseases, at least certain of them, may 
enter the milk, so as to give rise to the same diseases in the infant. 



Differences in Suckling- Women as Regards Quantity and 
Quality of Milk. 

There is a great difference, in different women, as regards the 
quantity and quality of their milk, and even the mode in which it is 
secreted. The best wet-nurses are usuallv robust without beino; cor- 



40 W E I G 1 1 T , G R O W T H , LACTATIO N . 

pulent. Their appetite is good, and their breasts arc distended from 
the number and large size of the bloodvessels and milk-ducts. There 
is but a moderate amount of fat around the gland, and tortuous veins 
are observed passing over it. Such nurses do not experience a feeling 
of exhaustion and do not suffer from lactation. 

The nutriment which they consume is equally expended in their own 
sustenance and the supply of milk. There are other good wet-nurses 
who have the physical conditions which I have described, but whose 
breasts are small. Still, the infant continues to nurse till it is satisfied, 
and it thrives. The milk is of good quality, and it appears to be 
secreted, mainly, during the time of suckling. Other mothers evidently 
decline in health during the time of lactation. They furnish milk of 
good quality and in abundance, and their infants thrive, but it is at 
their own expense. They themselves say, and with truth, that what 
they eat goes to milk. They become thinner and paler, are perhaps 
troubled with palpitation, and are easily exhausted. They often find 
it necessary to wean before the end of the usual period of lactation. 
There is another class whose health is habitually poor, but who furnish 
the usual quantity of milk without the exhaustion experienced by the 
class which I have just described. The milk of these women is of 
poor quality. It is abundant, but watery. Their infants are pallid, 
having soft and flabby fibre. All these kinds of wet-nurses are met in 
practice. 

Occasionally, a considerable part of the milk is lost by oozing from 
the breast. This sometimes occurs in robust women, but is more fre- 
quently associated with weakness. It is then due to a relaxed state of 
the orifices of the milk-ducts. Galactorrhcea, as the excessive secretion 
and flow of milk are designated, is said to be often associated with a 
menorrhagic diathesis : that is, women whose menses have been profuse 
are apt to have too abundant a flow of milk, corresponding with the 
menorrhagia. It is said that galactorrhcea is also apt to occur in those 
who are subject to discharges from parts which sustain no immediate 
relation to the breast, as in cases of hemorrhoidal flux, diabetes insi- 
pidus, etc. Excitement, or irritation of the uterus or ovaries, may serve 
as an exciting cause of galactorrhcea in those predisposed to it, and 
excessive suckling may have the same effect. 



Scantiness of Milk ; its Causes and Treatment. 

Though the amount of breast-milk which the infant requires is less 
than was estimated by Gumming, still insufficiency of this secretion is 
not uncommon, especially in cities. According to the statistics of Drs. 
Merei and Whitehead, among healthy mothers there is insufficiency 
in 16.5 per cent., while among mothers in feeble health the percentage 
is 46.6. In treating of this subject in the following pages, reference is 
not had to those cases in which there is temporary diminution of milk 
from acute disease or other perturbating causes, but to those cases in 
which there is habitual scantiness. 

One cause of scanty secretion of milk is a life of privation or of daily 



SCANTINESS OF MILK. -ii 

work, which necessitates separation from the infant. Insufficient food 
may render the milk more watery, as has already been stated, or it may 
cause diminution in its quantity. The mother thus situated is pallid. 
She is subject to palpitation and attacks of faintness. Her condition, 
indeed, is that of anaemia. Working women have scantiness of milk, 
not only in consequence of hardships, but also because they are usually 
separated for hours from their infants. Age is also a cause of scanti- 
ness of milk. Mothers at the age of forty years ordinarily furnish less 
milk than between twenty and thirty. Those who have not borne 
children till late in life, and whose mammary glands have, therefore, 
long been inactive, have less milk than those who commence bearing- 
children at the usual period. 

Eouth speaks of hyperemia as a cause of defective lactation. " This 
is a variety," says he, "which I have chiefly observed among hired wet- 
nurses, selected from the poorer classes, and admitted into wealthier 
families. . . . When feeding at the expense of a master or mistress, 
the amount they devour often surpasses all moderate imagination. They, 
in fact, gormandize. If in such instances a wet-nurse be given all she 
asks for, she will be found often to eat quite as much as any two men 
w T ith large appetites; and, as a result, she becomes gross, turgid, often 
covered with blotches or pimples, and generally too plethoric to fulfil 
the duties of her position. The plethora, as first induced, is of the 
sthenic variety, but it soon assumes an asthenic character, and, as the 
immediate result, the breast no longer secretes its quantum of milk. 
There may be good milk secreted, but it is in small quantity, and this 
quantity diminishes daily. The breast may also enlarge, but it is from 
a deposition of fatty tissue in and about it, as in other parts of the 
body. The veins on the surface become less apparent, always a bad 
feature in a suckling breast, till finally the flow of milk ceases alto- 
gether." 

Atrophy of the breast from the employment of iodine, or from long 
disuse, is also a cause of insufficiency of milk. 

It is so necessary for the health and development of the infant that 
the milk should be in proper quantity as well as quality, that it is best 
in a work of this kind to consider the treatment of insufficient secre- 
tion, and, on the other hand, of excessive secretion and loss of milk, or 
galactorrhoea, and first of insufficient or scanty secretion. 

The most efficient mode of increasing the lacteal secretion is that 
which is also natural, namely, suction from the nipple. There are 
many cases on record in which this has produced the flow of milk in 
women who have never borne children, and even in men. Baudelocque 
mentions the case of a girl, eight years old, who suckled her brother 
for a month, and cases at the opposite extreme of life have been re- 
ported ; one of a women of seventy years, who wet-nursed a grandchild 
twenty years after her last confinement. 

The following case, wdiich was under my observation, is interesting 
in this connection : Lizze S. was confined with her first child on May 
30, 1876. When the baby was a few days old, and before she had 
left the bed, she had inflammatory symptoms which proved to be due 
to pelvic cellulitis. Its course was tedious ; her milk diminished, and 



42 WEIGHT, GROWTH, LACTATION. 

its secretion soon ceased. On or about the first of August she began 
to sit up, and on August 11th she was admitted into the Sixty-first 
Street branch of the Infant Asylum, pale and wasted, but with return- 
ing appetite. She had no mammary secretion for eleven weeks, and 
her breasts were small and flabby. She had two fistulous openings, one 
vaginal, and the other low clown in the back, near the lower end of the 
sacrum or the coccyx. The baby was in a fair condition, having been 
suckled by other women. Experiences in this and other institutions 
show that infants having breast-milk do far better and are much more 
likely to live than those without breast-milk, and the mother was therefore 
advised by one of the managers — himself a physician — to suckle her 
baby, although there was not a drop of milk in her breast, and nursing 
had been suspended eleven weeks. To the surprise of the mother, and 
of the nurses in the house — to whom the procedure seemed very ridicu- 
lous — milk began to appear in a few days. The mother left the insti- 
tution October 8th ; but before her departure she was able to furnish, 
perhaps, two-thirds the quantity of milk which her infant required. 
This case affords practical illustration of the fact that frequent nursing 
is the most efficient galactogogue. Mothers sometimes, having little 
breast-milk, suckle their babies at long intervals, and finally dis- 
couraged at the unproductive state of their breasts resort to weaning, 
when, by patience and more frequent lactation, they might become good 
wet-nurses. In the cities, and during the summer season, in which 
breast-milk is so much required, the history of cases like the above, and 
the more remarkable cases in which men and grandparents have had 
secretion of milk and have suckled infants, should induce the physician 
to withhold his consent to permature weaning, which the disheartened 
mother is apt to suggest, unless indeed he perceive other reasons for 
weaning apart from scantiness of milk. 

Travellers among barbarous nations or tribes have often observed 
these cases of unnatural lactation. Humboldt saw T a man, thirty-two 
years old, who gave the breast to his child for five months, and Captain 
Franklin, in the Arctic regions, met a similar case. Dr. Livingstone, 
in his African travels, says that he has examined several cases in which 
a grandchild has been suckled by a grandmother, and equally remark- 
able instances of lactation occur among the negroes of the Southern 
and Middle States. Professor Hall presented to his class in Baltimore, 
a male negro, fifty -five years old, who w T et-nursed all the children of his 
mistress. In these cases of abnormal lactation, so far as we have accu- 
rate records of them, it -is ascertained that the breasts w T ere torpid, and 
even sometimes, as in old people, atrophied till the nursing commenced. 
Titillation, or pressing of the nipple, caused an affiux of blood to the 
gland, and developed its functional activity, so that milk w T as produced 
for the sustenance of the nursling. Therefore, in case of scanty secre- 
tion of milk, the mother may increase the quantity by applying the 
infant often to the breast. If, dissatisfied with the small amount of 
nutriment wdiich it receives, it refuse to make the necessary suction, 
any other mode of gentle traction or pressure may be employed in 
addition. The occasional employment of another infant, or a pup, 
milking the breast with the thumb and fingers, or the gentle suction of 



SCANTINESS OF MILK. 43 

a breast-pump, aids in stimulating the secretion. One of the best breast- 
pumps kept in the shops is that to which the name " The Mother's Bless- 
ing ' ' has been applied. Forcible rubbing or traction of the breast defeats 
the purpose for Avhich it is employed. It produces too much irritation 
and tenderness. The best mode of stimulation is by nursing, as it is 
the natural mode, and the moral effect of the infant at the breast aids 
in promoting the secretion. 

Another mode of increasing the functional activity of the mammary 
glands is by the electrical current. The fact is established by physio- 
logical experiments, that glandular organs can be made to secrete more 
actively by the stimulus of electricity, and, accordingly, this agent has 
been sucessfully employed to promote the secretion of milk. In Routh's 
Infant Feeding several cases are related which show the beneficial effects 
of this agent (page 149 et seq.). Among them are six reported by Dr. 
Skinner, of Liverpool. In all these, one or two applications of the 
electrical current sufficed to restore the secretion. The following is 
Dr. Skinner's mode of employing this treatment : 

"1. Direct. — Both poles must terminate in cylinders, with sponges 
well moistened in tepid water. The positive pole is pressed deep into 
the axilla, while the negative is lightly applied to the nipple and the 
areola ; the current being no stronger than is agreeable to the patient's 
feelings. The poles are kept in this position for about two minutes. 

" 2. Intramammary. — The poles are to be, as it were, embedded in 
the mamma, and moved about, raising and depressing both poles at 
once in and around the organ for the space of another two minutes. 
The same is to be done to both breasts daily, until the secretion is pro- 
perly established. Hitherto one or two sittings have always sufficed in 
my hands." {Communication of Br. Skinner to Br. Routli.) 

In all cases of scanty secretion of milk, the regimen of the mother is a 
matter of importance. Personal and domiciliary cleanliness is essential 
for successful wet-nursing. A certain amount of exercise in the open 
air is conducive to the health of the mother, and to the secretion of 
abundant and healthy milk. A case is related to show the effect of 
fresh air and outdoor exercise on the lacteal secretion. ' A lady of 
cleanly habits, living in London, had a very scanty supply of milk. 
She removed to the pure air of the seashore, and immediately the 
quantity became abundant, and continued so for months. Such cases 
are not infrequent. A mode of life that contributes to the general 
health of the mother will not fail to augment the quantity of her milk, 
if it be scanty, and to improve its quality. 

Much has been written in reference to the diet of women who suckle. 
It is a popular belief that certain articles of food promote the secretion 
of milk much more than other articles, though equally nutritious. No 
doubt, writers have erred in recommending exclusively this or that 
kind of food, as most likely to produce milk. The exact kind of food 
which is preferable, in a certain case, depends partly on the physique 
of the individual, and partly on the character of the food to which she 
has been accustomed. A mixed diet contributes most to the sustenance 
of the mother, and to an abundant secretion of milk. Animal sub- 
stances which furnish a due supply of nitrogenous aliment should be 



44 SELECTION OF A WET -NURSE. 

given with the farinaceous. Mothers pallid, and inclining to an anaemic 
condition, require a larger proportion of animal diet than those in good 
general health, On the other hand, plethoric women, such as Routh 
describes, who with excellent appetite consume large quantities of food, 
and who become more and more full-blooded and corpulent while the 
milk diminishes, require a more restricted animal diet, in connection 
with more exercise, especially in the open air. 

There are certain kinds of food which do appear to have a galacto- 
gogue effect with most wet-nurses. Oatmeal gruel is one of these. 
Wet-nurses often remark, after taking a bowl of this, that they feel the 
flow of milk. Cow's milk with some has a similar effect. Porter or 
ale, taken once or twice a day, also promotes the secretion of milk, 
especially in those who have poor appetite, and whose systems are some- 
what reduced. 

A great variety of medicines has been used for their supposed 
galactogogue effect. Medicines which improve the general health are, 
no doubt, sometimes useful for this purpose, such as the vegetable and 
ferruginous tonics and, perhaps, cod-liver oil. But there are other 
medicines which it is claimed have a specific effect on the mammary 
gland, promoting its secretion. Lettuce, winter-green, fennel, the 
broom tops (scoparius), and marsh-mallow, have been used for this 
purpose. There can be no doubt that the aromatic stimulants, as 
fennel, anise, and caraway seeds, given in soups, sometimes stimulate 
the lacteal secretion. Another medicine which has been recommended 
to the profession, as a galactogogue, is castor oil and the plant from 
which it is derived. 



CHAPTER V. 

SELECTION OF A WET-NUKSE. 

In the cities, cases are frequent in which mothers, with all possible 
care or endeavor, find themselves unable to suckle their infants. Their 
health is too poor, or the milk possesses the properties of colostrum, or 
it is no longer secreted, on account of nervous excitement, or exhaus- 
tion, or inflammation of the breasts. The number of such cases in the 
city would surprise physicians who are familiar only with the healthy 
and robust mothers of the country. The infant thus deprived of the 
mother's milk should, if practicable, be furnished with a wet-nurse. 

The selection of a wet-nurse often devolves upon the physician, and 
is a duty of great responsibility. It is better to select one between the 
ages of twenty and thirty years, and one who has suckled an infant 
previously. A- wet-nurse between the ages of twenty and thirty is 



EXAMINATION OF WET-NURSE. 45 

usually more active, cheerful, and conciliatory than one of a more ad- 
vanced age, and her milk is more apt to be abundant and nutritious. 
Those who have previously suckled and had charge of infants, are obvi- 
ously more competent to serve as wet-nurse than are primiparse. The 
milk of a wet-nurse whose infant is under the age of six months, will 
ordinarily agree with a new-born infant. If above that age, it some- 
times agrees, but often does not. 

The most difficult and responsible task imposed on the physician in 
the selection of a nurse, is to ascertain the exact condition of her health, 
and the quantity and quality of her milk. Constitutional syphilis is 
common in the class of women who present themselves for wet-nursing ; 
it is often latent, or its symptoms are easily concealed, and it is com- 
municable by lactation. The virus may be received by the infant from 
fissures or excoriations of the nipple. The nursling tainted by syphilis 
may, on the other hand, communicate the disease to the nurse through 
the same source. It is not fully ascertained whether the syphilitic 
virus may be conveyed to the infant by the milk. But the cases which 
have accumulated in the records of medicine are numerous, in which 
infants, born of healthy parents, have been fully syphilized by lactation 
from diseased nurses (see article Syphilis). These infants have some- 
times led a short and miserable existence, and have occasionally in- 
creased the misery of the household by imparting the disease to others. 
The duty is, therefore, imperative on the part of the physician to ex- 
amine carefully the wet-nurse, in reference to any evidences of the 
syphilitic taint. Acquainted with the symptoms of syphilis, he may 
usually, by shrewd questioning and by careful examination of the pres- 
ent appearance and condition of the woman, ascertain with considerable 
certainty whether her system has ever been infected. References should 
also be obtained and consulted, and, if practicable, the physician who 
has attended her be communicated with. 

It is safer to employ a wet-nurse, two months after her confinement 
than previously, for if she have the syphilitic taint it will by this time 
show itself in the innutrition, coryza, and anal sores of her infant. 

There are, also, among the women who present themselves for wet- 
nursing in the cities, many of a scrofulous habit, and many who possess 
an hereditary tendency to tuberculosis, if indeed they do not already 
have the incipient disease. Such applicants should be rejected, on 
account of the poverty of their milk and the probability that they will 
not be able to endure the debilitating effect of lactation. 

The milk should be examined, in order to ascertain its richness and 
quantity, and whether it contain colostrum. If there be colostrum after 
the eighth day, it is probable that there is some fault in the health or 
digestion of the wet-nurse, and that her milk may disagree with the 
infant. It is not necessary that the breast should be large, in order to 
furnish a sufficient quantity of milk, since, as has been already stated, 
in some the secretory function is active during the time of each nursing, 
so that, although the breasts are of moderate size, a sufficient amount 
of milk is furnished. The nipples should be well formed and promi- 
nent, and preference is to be given to those wet-nurses in whom blood- 
vessels are seen ramifying over the breasts. 



46 SELECTION OF A WET-NURSE. 

By examination of the milk, its degree of richness can be readily 
ascertained. A quantity of it should be placed in a test-tube, and the 
cream which rises to the top indicates, approximately, the character of 
the milk. Good milk furnishes three per cent of cream, and the casein 
and sugar usually correspond in quantity with the cream. An instru- 
ment has been invented, called the lactometer, by which the exact 
amount of the cream can be ascertained. It is simply a tube graded 
into 100 divisions. It is placed upright and filled with milk, and the 
number of divisions occupied by the cream indicates its proportion in 
100 parts. The lactoscope is another instrument employed for the pur- 
pose of ascertaining the richness of the milk. It consists of two 
concentric tubes, which move upon each other. Milk which we wish to 
examine is poured within the tubes sufficient to obscure a light viewed 
through it, three feet distant. The column of milk is then diminished, 
till the light begins to be visible. The size of the column indicates the 
degree of opacity and the richness. The lactoscope was invented by 
M. Donne, and is described by him. 

Dr. Minchin recommends a simple mode of determining the richness 
of cow's milk, and it would equally answer for the breast-milk. A 
vessel holding about one ounce, and containing a graduated enamel 
slab, passing diagonally from above downward, is filled w T ith milk. It 
is then covered with a glass slide carried over it in such a way as to ex- 
clude bubbles. The number of degrees w T hich can be read, indicates 
the character of the milk, as regards its richness. 

Examination of the milk by the microscope not only enables us to 
determine whether there are abnormal corpuscles or granular elements, 
but also its richness. It should be examined before the cream has 
separated. Oil-globules of small size, and few, indicate poverty of the 
milk ; very large oil-globules are said to indicate milk which is apt 
to be indigestible, especially in feeble infants. Such are the free 
globules of the colostrum. Numerous oil-globules of medium size indi- 
cate nutritious milk. Vogel, in 1850, made the discovery of vibriones 
in human milk. The fact is established that these animalcules may be 
generated in the milk within the breast, though such cases are not fre- 
quent. Dr. Gibb describes a case which he met. (Rankiyigs Abstract^ 
vol. xxxiv.) An infant, seven weeks old, wet-nursed by its mother, 
who had the appearance of perfect health, was, nevertheless, ill-nour- 
ished and emaciated. It had no diarrhoea or other apparent disease, 
and the milk was therefore examined. Vibriones baculi were found in 
the milk immediately after it was obtained from the breast. The milk 
had the usual amount of cream, and seemed, to the naked eye, of good 
quality. According to Dr. Gibb, two genera of microscopic organisms 
occur in the milk, namely, vibriones and monads. It is believed that 
the monads occur in consequence of fermentation of the sugar and the 
production of lactic acid. Vogel also attributed the production of the 
vibriones to fermentation occurring in consequence of heat and conges- 
tion of the breast, connected with sexual excitement. This explanation 
is probably not correct, because vibriones sometimes occur when there 
is no unusual heat of breast, and no evidence of fermentation. The fact 
that such organisms may be found in milk which seems of good quality 



EXAMINATION OF WET-NURSE. -17 

to the naked eye, affords additional proof of the usefulness of the 
microscope in the selection of a wet-nurse. 

Many wet-nurses have a return of the menses as early as the fourth or 
fifth month after delivery. The reestablishment of this function in some 
women impairs the quality of the milk, so as to render it less nutritious, 
and perhaps less digestible during the time of the catamenial flow, as 
we have stated in a preceding paragraph. In the selection of a wet- 
nurse, then, preference should be given to one Avho does not have the 
periodical sickness; but if she be already employed, and give satisfac- 
tion, the reappearance of the catamenia does not indicate the need of 
the change of nurse, unless the digestion of the infant be disordered, or 
its nutrition be impaired. 

In the selection of a wet-nurse, attention should also be given to her 
mental and moral traits. Cheerfulness, affection, veracity, and a proper 
appreciation of the responsibility of her situation, enhance greatly the 
value of a wet-nurse. Not less important are habits of temperance and 
cleanliness. I could cite cases of the most melancholy results from the 
absence of these traits. In one case, idiocy resulted from an infant falling 
upon the pavement from the arms of a reckless or intemperate wet-nurse. 

In most cases, the mode of examination indicated above suffices to 
show the character of a wet-nurse, so far as her health and milk are 
concerned. It should be borne in mind, however, that the microscope 
does not always reveal deleterious properties in the milk. Elements 
which are in a state of solution, and are invisible, may occur in excess, 
so as to impair the quality of the milk and render it indigestible. The 
following case, in which the saline ingredients seem to have been in 
excess, is related by Dr. Hartmann (British and Foreign Bledical 
Meview, vol. xii.) : "An infant, whose mother was in good health and 
had borne several children, exhibited a healthy appearance for the first 
five weeks after birth. The alvine evacuations then became copious, 
fluid, and discolored, and the child lost flesh and strength. After the 
usual remedies had been vainly administered for a fortnight, the mother 
remarked that the child did not take the right breast willingly, and so 
much did the unwillingness increase, that at length the mere applica- 
tion of the nipple to the child's lips occasioned loud crying. On ex- 
amination it was found that the milk of the right breast had a distinctly 
saline taste ; whereas the milk of the opposite breast was of the ordinary 
sweetness ; no difference of consistence or color was discoverable. From 
that time the child was only allowed to nurse the left breast, and in a 
few clays all diarrhoea and sickliness of appearance vanished." In this 
case there was no appreciable disease of the breast, although its secre- 
tion was perverted. The deleterious character of the milk was dis- 
covered, not by any change in its appearance, but by the taste. 

It is obviously very necessary, before recommending a wet-nurse, to 
ascertain whether she will probably furnish sufficient milk ; for however 
excellent she may otherwise be, if she do not satisfy the wants of the 
infant she obviously should not be employed. The only certain way of 
ascertaining whether she have or have not sufficient milk is by weighing 
the baby before and after the nursing, and observing whether the dif- 
ference in the two weights corresponds with that given in the tables in 
Chapter VII. 



48 COURSE OF LACTATION — WEANING. 



CHAPTER VI. 

COURSE OF LACTATION— WEANING. 

After the birth of the infant, the mother needs rest a few hours — 
four or five, or a little longer in tedious and exhaustive cases — and then 
it should be applied to the breast. There is frequently a little milk at 
this time, and the act of nursing promotes the secretion, and increases 
the quantity. The full secretion is not, however, established before 
the third day, and though the infant be applied to the breast often, it 
obtains but little milk. Infants are so constituted that they require 
but little food until it is naturally provided for them, and the common 
practice of feeding them to repletion with various sweetened mixtures 
almost as soon as life begins, because they obtain little breast-milk, is 
to be deprecated. Filling their stomachs in this way has a tendency 
to prevent their drawing upon the nipples with the avidity which is 
required to stimulate a free flow of milk. Besides, as I have many 
times observed, indigestion, diarrhoea, and sprue, are common results 
of this injudicious feeding. If, therefore, the infant be applied to the 
breast every second hour when the mother is awake till the third day, 
and be fed nothing besides, there need be no anxiety as regards its 
nutrition. If on the third day the breasts do not begin to fill, and the 
secretion be delayed, a little fresh cow's milk, diluted with double its 
quantity of warm water, and slightly sweetened, should be given every 
fourth hour, but should be withheld as soon as the flow of milk occurs. 

Infants under the age of one month should nurse about every hour 
by day and at longer intervals by night, or about ten times in twenty- 
four hours, for the stomach of the new-born holds but little, and, there- 
fore, receives but little at each nursing, and its digestion is active. 
The interval should be longer at night than in the davtime, so as to 
allow the mother more sleep. In the second month the interval should 
be about two hours, and it should be gradually lengthened as the age 
increases, so that after the fourth month nursing should be about every 
third hour, and after the sixth month, when the use of some artificial 
food is proper, every fourth hour. 

The infant should be habituated to nursing at regular intervals, and 
when it is, it will ordinarily awaken at about the proper time. The 
practice on the part of the mother of applying the babe to the breast 
whenever it frets, and as a means of quieting it, although it have but 
just nursed, is pernicious and should be forbidden. Giving the stomach 
no time to rest or filling it to repletion, tends to produce indigestion and 
diarrhoea, and to increase the fretfulness. The cause of the fretfulness 
should be sought for, that the proper measures may be applied. In 
ignorance of the cause, it is better to quiet the restlessness by carrying 
the child, or even by rocking it, than to increase the task of the diges- 



AILMENTS OF NURSING INFANTS. 49 

tive function. Fretfulness of infants is often due to colic or griping 
produced by irritating products of imperfect digestion in the intestines, 
and the addition of more food has a tendency to increase rather than 
to diminish it. 

While regularity in nursing is required, still, as M. Donne has said, 
mathematical exactness in this matter would be ridiculous. Quiet 
natural sleep of a well-nourished infant should not be interrupted in 
order to give it the breast, unless the sleep be unusually protracted. 
It will usually awaken when the system requires more nutriment. Ill- 
nourished infants often sleep but little, making known their want by 
crying and fretfulness, until they become wasted and prostrated, when 
they are drowsy in consequence of passive congestion of the brain. 
This drowsiness is evidently a pathological symptom. It shows the 
need of increased nutrition. It is due to scantiness of milk or milk of 
poor quality, and the infant should be aroused frequently for the pur- 
pose of giving it nutriment or even stimulants. The breast-milk is 
sufficient for its nutrition till the age of six or eight months, provided 
that it is abundant and of good quality. Therefore, if the mother be 
strong, and experience no exhaustion from suckling, no other nutri- 
ment need be given till that age. 

Many mothers, however, by the third or fourth month of lactation, 
find that they have not sufficient milk to meet the wants of the infant. 
The constant drain upon their systems sensibly impairs their health. 
In such cases it is proper to commence with a little feeding from the 
spoon or bottle, and increase the quantity given as the infant grows 
older. Great care is, however, requisite in the preparation of food for 
so young an infant, whose digestive organs are still feeble and easily 
deranged. In the country, where diarrhoeal aifections and the so- 
called gastric derangements are not frequent, the danger from artificial 
feeding is less than in the city, and in the cool months in the city the 
danger is less than in the summer season. Infants of the city, between 
the months of May and October, have a strong predisposition to diar- 
rhoeal attacks, the result of antihygienic influences which surround 
them. Errors of diet in their case readily provoke disease or derange- 
ment of the digestive organs, often of a severe and dangerous form. 
Moreover, experience has shown that artificial feeding, during the 
period when nature designed that they should be nourished by lacta- 
tion, very commonly produces in the hot months more or less vomiting 
and diarrhoea, followed by emaciation and other evidences of mal- 
nutrition. Therefore an exception must be made, in case of the city 
infant, as regards the commencement of artificial feeding. If it be 
under the age of one year, it should be nourished exclusively, or almost 
exclusively, at the breast during the hot months, when practicable, 
even if the mother suffer somewhat in her health from the constant 
drain upon her system. It should, however, receive the amount of 
nutriment which it requires, and, if there be not sufficient breast-milk, 
it will be necessary to supply the deficiency by artificial feeding. The 
reader is referred to Chapter VIII. , for facts relating to the subject of 
artificial feeding. 

No fixed rule can be stated in regard to the time when it is proper to 

4 



50 COURSE OF LACTATION — WEANING. 

allow artificial food in addition to the breast-milk. While robust mothers 
with abundant milk can satisfy their infants till the age of six or seven 
months, many begin to feel the drain upon their systems and have an 
insufficient supply by the third or fourth month, and it is necessary to 
supplement the nursing by the use of artificial food, a smaller or larger 
quantity, as the case may require. The deficiency may be supplied by 
the use of food prepared as recommended in Chapter VIII. At six 
months also, or even at four or five months, if the infant appear anaemic 
and ill-nourished, it may be allowed occasionally one or two teaspoonfuls 
of beef-juice, expressed from slightly boiled beef, two or three times 
daily. At the age of eight months, semi-liquid food may be given. 
Pap, prepared with stale bread or a rolled soda cracker, may also be 
given once or twice daily, between the times of nursing, and occa- 
sionally beef-tea or chicken-broth, thickened with cracker or bread, is 
taken with relish, and if well prepared and given no oftener than once 
or twice a day, it is commonly readily digested, while it is highly nutri- 
tious. If the quantity of breast-milk diminish, as it often does, toward 
the close of the first year, artificial food should be given oftener, so as 
to supply the deficiency. Solid food requires considerable development 
of the digestive organs for its ready assimilation. It should not, there- 
fore, be given till the close, or near the close, of the first year. 

Weaning ought to take place, as a rule, between the ages of ten and 
twelve months. It is well, if the mother's health be good and her milk 
sufficient, to defer weaning till the canine teeth appear. The infant 
then possessing sixteen teeth, is able to masticate the softer kinds of 
solid food. Weaning should be gradual. Mothers often speak of 
weaning on a certain day. They have given but little artificial food, 
and have suckled at regular intervals, till at a fixed time they have 
denied the breast altogether. This abrupt change of diet should be 
discouraged. It should only be recommended under peculiar circum- 
stances. It is apt to derange the digestive organs, and it causes fret- 
fulness and sleeplessness on the part of the infant for a week or more. 
W 7 eaning should commence by feeding with a spoon, a little oftener 
through the day, and nursing less, and by discontinuing the practice of 
suckling at night. The infant tolerates this gradual change of diet, 
while it rebels against sudden weaning, and by its fretfulness increases 
greatly the care and trouble of the mother. Nurslings in the city 
should not be weaned in warm weather, nor within a month imme- 
diately preceding it. If the mother's health fail, or her milk become 
deficient in the summer months, so that she cannot continue suckling, 
the infant should be sent immediately to the country,' or a wet-nurse 
be employed. Many lives are sacrificed in consequence of ignorance 
of the danger of weaning under the circumstances mentioned. Severe 
diarrhoea, inflammatory or non-inflammatory, is apt to result. This 
subject will be considered elsewhere. 



QUANTITY OF FOOD REQUIRED. 51 



CHAPTEE VII. 

QUANTITY OF FOOD REQUIRED I]S T INFANCY AND CHILDHOOD. 

The quantity and quality of food required in infancy and childhood 
is a subject of the highest importance, and one in regard to which much 
ignorance prevails. Children need food more frequently than adults, 
and they suffer more from hunger if their meals are delayed beyond the 
usual time. Their tissues undergo more active molecular change than 
those of adults, so that they need more nutriment for the waste, and they 
require additional nutriment for the purposes of growth. It is during 
infancy that the most disastrous consequences follow from errors in 
nursing or feeding. Numberless infants every year, and especially in 
the summer months, lose their lives from this cause. Improperly fed, 
they soon show symptoms of indigestion and gastrointestinal catarrh. 
Their food, if unsuitable in quality or too abundant for their digestive 
function, is assimilated with difficulty, and only in part. More or less 
of it undergoes fermentation, producing lactic and butyric acids, and 
other irritating products, which cause diarrhoea; and if the error is not 
soon corrected, the catarrh of the alimentary tract thus established 
results in waste of the tissues, and, finally, a marasmic condition occurs, 
in which the child perishes, or from which it very slowly recovers under 
better diet and improved hygienic surroundings. 

So important to the welfare of young children is the diet, both as 
regards its quantity and quality, and the times of feeding, that this 
subject has attracted much attention, and many infant foods have been 
prepared, which are found in the shops. Both underfeeding and over- 
feeding, as well as the use of improper diet, produce ill-effects. If 
infants be underfed, they fret, and lose flesh and strength; if overfed, 
they may vomit the surplus food, but if this do not occur, that portion 
which is not digested undergoes fermentation, with the formation of the 
irritating products mentioned above. 

Appreciating the importance of a correct knowledge of the amount 
of food required by infants, certain physicians have made careful obser- 
vations in order to ascertain it. M. Parrot (L. Athrepsie, Paris, 1877) 
weighed infants before and after each feeding with cow's milk. The 
number of feedings was six in twenty-four hours. His observations 
were scarcely sufficient in number for accurate deductions, but he con- 
cluded from them that the quantity of cow's milk required in twenty- 
four hours is as follows: "9j ounces for the first month; 19 ounces for 
the second, third, fourth, and fifth months; and 25 ounces for the sixth 
month." This estimate is for pure cow's milk used without dilution. 
The use of milk in its pure state and undiluted, he considers preferable 
to its dilution. After the sixth month he thinks that 4J to 6J- ounces 
for each month should be added to the quantity previously employed. 



m 



QUANTITY OF FOOD REQUIRED 



Meigs and Pepper mention the case of an infant of four months that 
took 36 ounces of breast-milk daily, and another of five to six weeks, 
that took 18 to 23 ounces daily. The same authors cite the observa- 
tions of M. Bouchard, who concludes from weighing infants, that while 
the new-born require much less breast-milk than those who are older, 
20 ounces daily are needed between the ages of one and three months, 
23 ounces after the third month, 27 ounces after the fourth month, and 
30 ounces between the ages of six and nine months. 

A few years since, Drs. Chadbourne, Parker, and myself, made ob- 
servations in the New York Infant Asylum and New York Foundling 
Asylum, in order to determine how much food children required at 
different ages. Those selected for observation were well nourished, and 
they were accurately weighed before and after each nursing or feeding 
during twenty -four hours. Eleven infants under the age of three weeks, 
who nursed, with three exceptions, twelve times in twenty-four hours, 
were found to take in the average in the day and night 12.55 ounces, 
as seen by the following table : 





Table I. — New-born Infar 


is, 


those under 


the Age 


of Three Weeks. 










Milk nursed 


in 24 hours. 








No. of 






No. 


Name. 


Age. 


nursings. 


Quantity in 
weight. 


Quantity in 
fluidounces. 










Oz. Dr. 




1 


Josephine Foley . 


17 d. 


11 


10 l 


9.75 


2 


Henry Cunningham 






16 d. 


9 


13 5" 


13.24 


3 


Henry Jackson 






19 d. 


9 


10 3 


10.07 


4 


Rake 








5 d. 


12 


22 7 


22.22 


5 


Henry Benton 








6 d. 


12 


15 5i 


15.25 


6 


Wm. Fletcher 








5 d. 


12 


10 H 


9.88 


7 


Nora Hastie . 








14 d. 


12 


17 3 


16.85 


8 


Carl Flask . 








5 d. 


12 


5 4 


5.37 


9 


Frederick Dighle 








7 d. 


12 


14 4 


14.08 


10 


Edward Stace 








6 d. 


12 


8 1 


7.74 


11 


Kosa Brown . . 








3 w. 


12 


14 1 


13 68 



The above statistics correspond with those of other observers. They 
show that infants under the age of three weeks take in the average 
about half the milk required by those over the age of two or three 
months. After the third week, the amount needed for healthy nutri- 
tion gradually increases with the progressive growth of the infant. 



QUANTITY OF FOOD REQUIRED. 



53 



Table II. — Ages; from One Month to Ten Months. 









No. of 


Milk nursed 


in 24 hours. 


No 


Name. 


Age. 


nursings. 


Quantity in 
weight. 


Quantity in 
fluidounces. 










Oz. Dr. 




1 


Agnes Sunkle 


6 m. 


8 


26 1* 


25.3 


2 


Jessie Bradley 






4 m. 


9 


38 J 


36.8 


3 


Walter Gorman . 






3|m. 


8 


24 2" 


23.5 


4 


Lottie Brooks 






7 in. 


10 


27 3i 


26.6 


5 


Willie Loenard 






5£ m. 


11 


28 7~ 


28.0 


6 


John Clay- 






5 m. 


10 


29 7 


29.0 


7 


Agnes West . 






3£ m. 


8 


19 2 


18.6 


8 


Freddy Yan Buren 






2~ m. 10 d. 


7 


24 4 


23.7 


9 


Eddie Wilson 






6 m. 


10 


12 4£ 


12.2 


10 


Frank Smith . 






3£m. 


8 


26 7 


26.1 


11 


Sarah White . 






4 m. 


8 


23 5 


22.9 


12 


John G-afney . 






9 m. 


8 


24 H 


23.4 


13 


Bernhard Joseph . 






7 m. 


8 


27 4 


26.6 


14 


Thomas Cole . 






6 m. 


10 


26 6£ 


26.0 


15 


Astie Kussell . 






6 m. 


10 


21 6~ 


21.1 


16 


Clarence Humphrey 






1 m. 5 d. 


8 


11 H 


10.84 



The second series of observations related to infants between the ages 
of one and ten months. It was found that they received in the average 
23.79 fluidounces of breast-milk in twenty-four hours. The number 
of nursings in the day and night varied from seven to ten. Therefore 
infants between the age of one or, perhaps more accurately, two months 
and ten months, if they take the breast eight times in twenty-four 
hours, receive three ounces at each nursing ; if they take the breast 
twelve times, they receive two ounces each time. 

The following observations were made by me in private practice. All 
the infants were well nourished, having the symptoms of normal hearty 
digestion. An infant since the age of four weeks, and at the time of 
my observation six weeks old, took at each feeding one and a half 
ounces of milk, one and a half ounces of water, and one teaspoonful of 
Liebig's food. When three or four weeks old, it took at each feeding 
one ounce of cow's milk, one ounce of water, and one teaspoonful of 
Liebig's food. It was fed six times in twenty-four hours. A second 
infant of eight weeks, large and rugged, took eight times daily two 
ounces of milk, two ounces of water, and two scant teaspoonfuls of 
Liebig's food. A third infant, aged two months, took at each feeding, 
eight times daily, one teaspoonful of Liebig's food in seven tablespoon- 
fuls of milk and water in equal parts. A fourth infant, aged one 
month and three days, fed every hour the mother stated, but perhaps 
the interval was longer at night, took in twenty-four hours forty -seven 
tablespoonfuls of the following mixture, or about two tablespoonfuls at 
each feeding : one heaped tablespoonful of Borden's condensed milk, one 
tablespoonful of lime water and ten of water. A fifth infant, which 
seems to have been a very hearty feeder, aged six months, took at each 
feeding and nine times in twenty-four hours, peptonized milk prepared as 



54 QUANTITY OF FOOD REQUIRED. 

follows : One tablespoonful of peptogenic powder (Fairchild's, designed to 
peptonize the milk), four tablespoonfuls of milk, four of water, and one 
of cream. The large quantity of nine tablespoonfuls at each feeding 
did not seem to produce any gastric distress. 

The above observations are designed to show the average amount of 
milk required by the infant, but some infants, like adults, need consider- 
ably more food than others, and the infantile stomach is so distensible 
that it holds more without discomfort than would seem possible in 
viewing it in the cadaver. Thus the infant of four months, observed by 
Meigs and Pepper, took thirty-six ounces of breast-milk in twenty-four 
hours, without apparent discomfort, and with a healthy and robust de- 
velopment of his system, while one-third less would have been sufficient 
for another infant. Of course, if the breast-milk furnished to the infant be 
too watery and deficient in nutritive properties, or if the cow's milk with 
which it is fed be too much diluted, the quanity of food which it takes 
and requires will be in excess of the average quantity. Thus the infant 
of six months alluded to above that took four tablespoonfuls of milk, 
four of water, and one of cream, would probably have done as well with 
two less tablespoonfuls of water, since in the smaller quantity it would 
have taken the same amount of nutriment. The importance of the 
above observations is apparent, for they enable us to determine 
approximately how much food should be given at each feeding to 
infants that are unfortunately deprived of the breast-milk. The quan- 
tity required, as indicated by these observations, may be stated as 
follows : Under the age of three weeks, from one ounce to one and a 
half ounces of cow's milk, diluted and prepared after it is measured, so 
as to resemble so far as .possible breast-milk, should be given at each of 
the twelve daily feedings. The quantity should be gradually increased 
as the infant grows older until the age of three months, when three 
ounces should be given at each of the eight feedings. It should be 
properly diluted after it is measured. Some infants do not seem to 
require an increase of this amount, but others who are hearty, need 
more. Thus infant No. 2, in the second table, at the age of four 
months, took in the average four ounces of breast-milk at each of the 
nine nursings in twenty -four hours. At the age of six months, the 
infant should be fed every three hours, and four ounces of milk may be 
given at each feeding, in order to insure a sufficient quantity. Some 
require less than this amount, and occasionally one needs a little more, 
as four and a half or even five ounces. 



QUANTITY OF FOOD REQUIRED. 



55 



Table III, — Observations Relating to the Diet during Twenty-four Hours, of 
Twenty-eight Healthy Children, between the Ages of Two and Three Years, 
with an Average Age of Two Years Eight Months. 







Total amount. 


Average 


for each. 




Breakfast. 










Bread 




6 lbs. 


4 oz. 1 dr. 


3.5 


oz. 


Butter . 






13 oz. 5 dr. 


0.45 


oz. 


Milk . 


Dinner. 


22 lbs. 


14 oz. 2 dr. 1 


12.7 


fl. OZ. 


Meat 




8 lbs. 


oz. 5 dr. 


4.6 


OZ. 


Potatoes 




6 lbs. 


13 oz. 7 dr. 


3.9 


oz. 


Milk . 


Supper. 


17 lbs. 


9 oz. 7 dr. 


9.4 


fl. oz. 


Milk . 




19 lbs. 


12 oz. 1 dr. 


10.5 


fl. oz. 


Bread 




7 lbs. 


1 oz. 2 dr. 


4.0 


oz. 


Butter . 






14 oz. 7 dr. 


0.53 


oz. 



DAILY AYERAGE FOR EACH CHILD. 



Bread 
Butter 
Meat (beef) 
Potatoes 
Milk . 



7.5 oz. avoir. 
0.98 oz. " 

4.6 oz. " 
3 9 oz. " 

32.6 fl. oz. 



Table IV. — Observations upon Twelve Children between the Ages of Three and 
Six Years: Average Age, Four Years Ten Months. 





Total amount. 


Average for each. 




Breakfast. 








Bread 




4 lbs. 6 oz. 


3} dr. 


5.86 oz. 


Butter 




5 oz. 


2 dr. 


0.427 oz. 


Milk 


Dinner. 


280 fl. oz. 




23.3 fl. oz. 


Beef 




9 lbs. 1 oz. 


3 dr. 


12.1 oz. 


Bread 




1 lb. oz. 


1 dr. 


1.6 oz. 


Rice 




9 lbs. 12 oz. 


7 dr. 


13.0 oz. 


Milk 




112 fl. cz. 




9.3 fl. oz. 


Butter 


Supper. 


2 oz. 


2h dr. 




Bread 




2 lbs. 4 oz. 


ljdr. 


3.0 oz. 


Butter 




5 oz. 


5Jdr. 




Milk 




192 fl. oz. 




16.0 fl. oz. 



DAILY AYERAGE FOR EACH CHILD. 



Milk. 
Beef . 
Rice . 
Bread 
Butter 



48.6 fl. oz. 
12.1 oz. avoir. 
13.0 oz. " 
10.3 oz. " 
1.08 oz. " 



1 354.6 fluidounces. 



56 



QUANTITY OF FOOD REQUIRED. 



Table V. — Observations Relating to the Diet of Twenty-Jour Children, Twelve 
Boys, Twelve Girls, between the Ages of Four Years and Ten Years: Average, 
Six Years Ten Months. 





Total amount. 


Average for each. 


Breakfast. 
Bread ....... 

Butter 

Milk 

Dinner. 

Roast beef 

Potatoes . . . . 

Bread 

Milk 

Butter . . . 

Supper. 

Bread 

Milk 

Butter 


7 lbs. 13 oz. 3 dr. 
12 oz. 3} dr. 
348 fl. oz. 

18 lbs. 11 oz. dr. 
15 lbs. 8 oz. 3 dr. 
1 lb. 6 oz. \ dr. 
192 fl. oz. 

U dr. 

6 lbs. 2 oz. 3J dr. 
384 fl. oz. 

11 oz. 5£ dr. 


5.21 oz. 
51 oz. 
14.5 fl. oz. 

12.46 oz. 
10.30 oz. 

0.92 oz. 

8 fl. oz. 

0.012 oz. 

4.1 oz. 
16.0 fl. oz. 
0.16 oz. 



daily average for each child. 



Roast beef 
Bread 
Potatoes . 
Butter . 

Milk 



12.46 oz. 
10.23 oz. 
10.3 oz. 
. 0.99 oz. 
38.5 fl. oz. 



Compare the above observations with those of Professor Dalton, who 
estimates that a healthy adult taking active exercise requires each day — 



Meat 
Bread 
Butter 

Water 



16 oz. 

19 oz. 

3£ oz. 

52 oz. 



while one leading a sedentary life needs considerably less. 

It will be seen by the above tables, that even more food appears to 
be needed during the period of childhood than in adult life. We would 
suppose this to be so without statistical evidence, for the active exercise 
and rapid and progressive growth of this period necessarily require a 
large amount of nutriment. Moreover, while adults do well with solid 
food and water, statistics show that the best diet for children who have 
passed beyond infancy, is one of milk with solid food, for at least 
breakfast and supper. 

Although we are able, by observations, to determine the average 
amount of food required in twenty-four hours, by children of various 
ages, it would be wrong to limit the diet to a fixed quantity, for some 
need more than others. A child should never go hungry after a meal. 
In some of the best conducted institutions of New York, the children 
eat of plain food all that they desire at each meal, while in other insti- 
tutions the food at supper is limited, but is abundant at the other meals. 
As children go to bed so soon after supper, it is proper to have this 
meal light, and of such food as is easily digested. 



ARTIFICIAL FEEDING. 



57 



CHAPTER VIII. 

ARTIFICIAL FEEDING. 

Occasionally the mother is unable to suckle her infant, and a hired 
wet-nurse cannot be or is not obtained. Artificial feeding is then 
necessary. In the large cities, this mode of alimentation for -young 
infants should always be discouraged, for it frequently ends in death, 
preceded by evidences of faulty nutrition. A considerable proportion 
of those nourished in this manner thrive during the cold months, but 
on the approach of the warm season they are the first to be affected 
with diarrhoea and other symptoms indicating derangement of the di- 
gestive function. In New York City a large proportion of the artificially 
fed infants,, who enter the summer months, die before the return of cool 
weather, unless saved by removal to the country. In the country, and 
in the small inland cities, the results of artificial feeding are much more 
favorable. In elevated farming sections, on account of the salubrity of 
the air, and the facility with which milk, fresh and of the best quality, 
is obtained, artificial feeding is attended by much less risk than in the 
cities. 

Young infants, fed by the hand, obviously require food prepared so 
as to resemble as closely as possible human milk in its composition. 
Woman's milk in health is always alkaline. It has a specific gravity 
of 1031.7 ; cow's milk has a specific gravity of 1029. That of cows 
stabled and fed upon other fodder than hay or grass is usually decidedly 
acid. That from cows in the country with good pasturage is said to be 
alkaline, but in two dairies in Central New York a hundred miles apart, 
in midsummer, with an abundant pasturage, two competent persons 
whom I requested to make the examinations found the milk slightly 
acid immediately after the milking in all the cows. 

The following results of a large number of analyses of woman's and 
cow's milk, made by Konig and quoted by Leeds, and of several of the 
best known and most used preparations designed by their inventors to 
be substitutes for human milk, show how far these substitutes resemble 
the natural aliment in their chemical characters : 





Woman's mill 






Cow's milk. 






Mean. 


Minimum. 


Maximum. 


Mean. 


Minimum. 


Maximum. 


Water 


87.09 


83.6 


90.90 


87.41 


80.32 


91.50 


Total solids . 


12.91 


9.10 


16.31 


12.59 


8.50 


19.68 


Fat . 


3.90 


1.71 


7.60 


3.66 


1.16 


7.09 


Milk-sugar 


6.04 


4.11 


7.80 


4.92 


3.20 


5.67 


Casein 


0.63 


0.18 


1.90 


3.01 


1.17 


7.40 


Albumen 


1.81 


0.39 


2.35 


0.75 


0.21 


5.04 


Albuminoids . 


1.94 


0.-57 


4.25 


3.76 


1.38 


12.44 


Ash ... 


0.49 


0.14 




0.70 


0.50 


0.87 



58 



A R T I F I C I A L F E EDIXG. 



The following analyses of the foods for infants found in the shops, and 
which are in common use, were made by Leeds, of Stevens's Institute. 



Farinaceous Foods. 



Water 

Fat . 

Grape-sugar 

Cane-sugar 

Starch 

Soluble carbohydrates 

Albuminoids 

Gum, cellulose, etc. 

Ash . 



1. 


2. 


;> 


4. 


5. 


Blanks 


Hubbell's 


Imperial 


Ridge's 


"A B.C" 


wheat food. 


wheat food 


granuni. 


food. 


Cereal milk 


9.85 


7.78 


5.49 


9.23 


9.83 


1.56 


0.41 


1.01 


0.63 


1.01 


1.75 


7 56 


Trace. 


2.40 


4.60 


1.71 


4.87 


Trace. 


2.20 


1540 


64.80 


67.60 


78.93 


77 96 


58.42 


13.69 


14.29 


3.56 


5.19 


20.00 


7.16 


10.13 


10.51 


9.24 


11.08 


2.94 


Undeterm'd 


0.50 




1.16 


1.06 


1.00 


1.16 


0.60 





Robinson's 

patent 
barley. 



10 10 
0.97 
3.08 
0.90 

77.76 
4 11 
5.13 
1.93 
1.93 







Liebig' 


s Foods. 












Mellin's. 


Hawley's 


Horlick's 


Keas- 

bey and 

Matti- 

son's. 


Savory 

and 
Moore's. 


Baby sup 
No. 1. 


Baby 

sup 

No. 2. 


Water 


5.00 


6.60 


3.89 


27.95 


8.34 


5.54 


11.48 


Fat .... 


0.15 


0.61 


0.08 


None. 


0.40 


1.28 


0.62 


Grape-sugar 


44.69 


40.57 


34.99 


36.75 


20.41 


2.20 


2 44 


Cane-sugar 


3.51 


3.44 


12.45 


7.58 


9.08 


11.70 


2.48 


Starch 


None. 


10.97 


None. 


None. 


36.36 


61.99 


51.95 


Soluble carbohydrates 


85.44 


76.54 


87.20 


71.50 


44.83 


14.35 


22.79 


Albuminoids 


5.95 


5.38 


6.71 


None. 


9.63 


9.75 


7.92 


Gum, cellulose, etc. . 










0.44 


7.09 


5.24 


Ash .... 


1.89 


1.50 


1.28 


0.93 


0.89 


Undeterm'd 


1.59 



MUk Foods. 



Nestle' s. 


Anglo-Swiss. 


Gerber's. 


American-Swiss. 


Water 


4.72 


6.54 


6.78 


5 68 


Fat 


1.91 


2.72 


2.21 


6.81 


Grape-sugar and milk-sugar 


6.92 


23.29 % 


6.06 


5.78 


Cane-sugar .... 


32.93 


21.40 


30.50 


36.43 


Starch 


40.10 


34.55 


38.48 


30.85 


Soluble carbohydrates . 


44.88 


46.43 


44.76 


45.35 


Albuminoids .... 


8.23 


10.26 


9.56 


10.54 


Ash 


1.59 


1.20 


1.21 


1.21 



It is seen by examination of the analyses of the above foods that all 
except such as consist largely or wholly of cow's milk differ widely 
from human milk in their composition, and although some of them — as 
the Liebig preparations, in which starch is converted into glucose by 
the action of the diastase of malt — may aid in the nutrition and be 
useful as adjuncts to milk, physicians of experience and close observa- 
tion agree that when breast-milk fails or is insufficient, our main re- 



goat's milk. 59 

liance for the successful nutrition of the infant must be on animal milk, 
Nestle's food, which consists of wheat flour, the yelk of egg, condensed 
milk, and sugar, and which has been so largely used in this country 
and in Europe, is probably beneficial mainly from the large amount of 
Swiss condensed milk in its composition. 

Cow's milk being readily obtained, is commonly used as a substitute 
for human milk, compared with which it contains less water and sugar, 
but more butter, casein, and salts. Its composition, however, varies 
considerably, according to the food of the cow and other circumstances. 
The variations in the milk of the cow, according to the nature of its 
food, have been considered in a preceding chapter. It has been stated, 
also, that the milk first obtained in milking is most watery, since it is 
longer secreted than the last milk, or the "stripping." The stall-fed 
cow gives milk that is moie acid than that of the pasture-fed cow. 
Again, the milk in the first months after calving is richer than after 
the lapse of several months. 

It is obvious from the above facts, that the analyses of different 
specimens of cow's milk must differ greatly, and the same is true of the 
milk of *the goat and ass, and probably of the ewe. In fact, different 
samples of the milk of the same animal may differ more from each 
other, in their chemical character, than the average milk of one animal 
from that of another. 

The milk of the goat and that of the ass have been recommended as 
food for infants in preference to cow's milk, on the ground that they 
more nearly resemble human milk. But bv reference to the foregoing 
table, it will be seen that more importance has been attached to this 
supposed resemblance than the facts justified. Neither the milk of the 
ass nor goat, so far as its chemical character is concerned, would seem 
to possess any marked advantage over cow's milk. The ass's milk is 
procured with difficulty, and is seldom used. An objection to goat's 
milk is the unpleasant odor which it often possesses, due to the presence 
of hircic acid. It is stated, however, by Parmentier, that this odor is 
only noticed in the milk of goats that have horns. An important ad- 
vantage, in the city, in the use of goat's milk, is that the animal can 
be kept at little expense, so that even poor families who are not able to 
purchase and feed a cow, can generally possess a goat from which fresh 
milk can be obtained at any time. Preference is to be given to goat's 
milk, when fresh, over cow's milk brought from the country, perhaps 
watered on the way, several hours old when received, and in commenc- 
ing fermentation. But cow's milk of good quality and free from fer- 
mentative changes, is probably not inferior to goat's milk as a food for 
infants, and from its abundance it must continue to be in common use 
for this purpose. 

If the mother's milk fail, or become unsuitable from ill-health or 
pregnancy, and on account of family circumstances a wet-nurse cannot 
be employed, the important duty devolves upon the physician of de- 
ciding how the infant should be fed. Shall one of the numerous foods 
in the shops be employed — some of which, as Liebig's, have real merit — 
or shall milk be used as the sole food, or be used in combination with 
some other food, and if so used, what shall be the mode of combination 



60 ARTIFICIAL FEEDING. 

and preparation? In order to solve this problem it will be well to 
recall to mind the part performed in the digestive function by the dif- 
ferent secretions which digest food: 

1st. The saliva is alkaline in health. It converts starch into glucose 
or grape-sugar. It has no effect upon fat or the protein group. It is 
the secretion of the parotid, submaxillary, and sublingual glands, which 
in infants under the age of three months are very small, almost rudi- 
mentary. The power to convert starch into sugar possessed by saliva 
is due to a ferment which it contains called ptyalin. 

2d. The gastric juice is a thin, nearly transparent, and colorless 
fluid, acid from the presence of a little hydrochloric acid. It produces 
no change in starch, grape-sugar, or the fats, except that it dissolves 
the covering of the fat-cells. Its function is to convert the proteids into 
peptone, which is effected by its active principle, termed pepsin. 

3d. The bile is alkaline and it neutralizes the acid product of gastric 
digestion. It has no effect on the proteids. It forms soaps with the 
fatty acids, and has a slight emulsifying action on fat. The soaps are 
said to promote the emulsion of fat. Their emulsifying power is 
believed to be increased by admixture with the pancreatic secretion. 
Moreover, the absorption of oil is facilitated by the presence of bile 
upon the surface through which it passes. 

4th. The pancreatic juice appears to have the function of digesting 
whatever alimentary substance has escaped digestion by the saliva, 
gastric juice, and bile. It is a clear, viscid liquid of alkaline reaction. 
It rapidly changes starch into glucose. It converts proteids into pep- 
tones and emulsifies fats. While the gastric juice requires an acid 
medium for the performance of its digestive function, the pancreatic 
juice requires one that is alkaline. These important facts should be borne 
in mind, that such a mistake as prescribing pepsin with chalk mixture, 
or the extractum pancreatis with dilute muriatic acid, may be avoided. 

5th. The intestinal secretions are mainly from the crypts of Lieber- 
kiihn, and their action in the digestive process is probably compara- 
tively unimportant, but in some animals they have been found to digest 
starch. It will be observed that of all these secretions that which 
digests the largest number of nutritive principles is the pancreatic. It 
digests all those which are essential to the maintenance of life except 
fat, and it aids the bile in emulsifying fat. 

It is seen from this brief review of the action of the digestive fer- 
ments, that starch is digested in only a very small quantity by infants 
under the age of three months ; and, therefore, that those foods which 
consist largely of starch afford but little nutriment at this age. The 
impropriety also of administering for days large quantities of an alkali, 
as is frequently done, is apparent from the above statement in regard 
to the action of pepsin, since it may retard or prevent gastric digestion. 

In 1882, a conference was held in Salzburg, Germany, of physicians 
from various parts of the German Empire, known throughout the world 
as specialists in the diseases of children. The purpose of the conven- 
tion was to discuss the diet of infancy and childhood. They agreed 
that animal milk is the best substitute for human milk in the feeding 
oi infants, either as the main food or as the basis of the food em- 



PEPTONIZED MILK. 61 

ployed. Useful as some of the preparations of the shops are as adjuvants, 
nevertheless, experience shows the soundness of the opinion expressed 
by the conference, and yet feeding with animal milk of the best quality 
must be carefully managed, or it will be found to disagree with the feeble 
and readily disturbed digestive function of the infant. 

Milk should always be given at a uniform temperature of about 
99°. Employed habitually too hot or too cold, it frequently produces 
stomatitis, or a more serious disease of the digestive organs. 

Infants under the age of ten months should nurse from the nursing 
bottle, and this as soon as used should, with the India-rubber top and 
attachment, be immersed in a quart or two-quart bowl of cold water, to 
which a teaspoonful of sodium bicarbonate has been added, and water 
should be drawn through the tube and nipple by suction with the mouth. 

Cow's milk, though possessing nearly the same composition as human 
milk, nevertheless behaves differently in some respects in digestion. 
The casein of human milk coagulates in light flocculi in the stomach 
of the infant, so as to be readily acted on by the digestive ferments, 
w T hile that of cow's milk forms large and firm coagula, which are with 
difficulty digested. The irritating products of a slow and imperfect 
digestion frequently cause colic, and fever, with more or less intestinal 
catarrh. Cow's milk, therefore, disagrees with many infants, who 
suffer from indigestion in consequence of the feeding, whose stools show 
masses of partly digested casein, with abundant mucus, who fret from 
gastro-intestinal uneasiness, and vomit often, and do not thrive like 
infants nourished at the breast. Therefore, the profession have long 
felt the need of some modification of cow's milk so that it more closely 
resembles human milk in its digestion. This has in a measure been 
accomplished by the process known as peptonizing, by which the 
casein is digested, or so far digested that it coagulates in flakes. Pep- 
tonized milk, or milk which is partially digested by artificial means, is 
prepared by the action upon it of extractum pancreatis and sodium 
bicarbonate. We may here briefly state the method. Extractum 
pancreatis 5j, and sodium bicarbonate 5\j, are added to one gill of tepid 
water, and this is mixed with one pint of tepid milk as fresh as possible. 
The mixture is allowed to stand in water having a temperature of about 
100° to 110°, for half an hour, or even one hour, if it do not become 
bitter. After the half hour the milk should be frequently tasted, and 
if it be in the least bitter, it should be immediately removed from the 
heat, and what is not used should be placed upon ice. If it be fully 
digested, it is too bitter for use. If it be slightly digested, the bitter- 
ness is not appreciable, or is so slight that it is readily taken by the 
infant, and the casein coagulates in flakes instead of large coagula. 
Observations in feeding in the New York Foundling Asylum, appeared 
to show that infants under the age of three months did better, if one 
pint of water instead of one gill were used with the pint of milk. 
Prof. Leeds recommends the following method as an improvement. 
In his opinion it produces milk so closely resembling breast-milk in its 
chemical character and behavior, that he designates it humanized cow's 
milk : 



62 ARTIFICIAL FEEDING. 

" 1 gill of cow's milk. 

1 gill of water. 

2 tablespoonfuls of rich cream. 
200 grains of milk-sugar. 

1J grains of extractum pancreatis. 
4 grains of sodium bicarbonate " 

"Put this in a nursing-bottle, place the bottle in water made so 
warm, that the whole hand cannot be held in it without causing pain 
longer than one minute Keep the milk at this temperature for exactly 
twenty minutes. The milk should be prepared just before using." 
Messrs. Fairchild have prepared according to the above formula what 
they designate a peptogenic powder in a can accompanied by a measure 
which holds sufficient for peptonizing two ounces of milk with half an 
ounce of cream. 

Peptonized milk is an useful addition to the dietetic preparations for 
infants. By peptonizing is accomplished what physicians have long felt 
the need of, to wit : a mode of preparing cow's milk, so that its casein 
coagulates in flakes like that of human milk. Milk employed for this 
purpose should be as fresh as possible, but unfortunately in hot weather 
when there is most need of having a food for artificially fed infants, 
which bears the closest possible resemblance to human milk, in order 
to prevent the summer diarrhoea, much of the cow's milk when it 
reaches the cities twenty-four hours after the milking, has begun to un- 
dergo fermentation, and is therefore unsuitable for peptonizing, though 
employed for this purpose. This is probably one of the chief causes of 
the fact that peptonized milk not unfrequently disappoints our expecta- 
tions, so that we find that the patient does better if fed with condensed 
milk or one of the foods of the shops. The peptonizing of milk rests 
on a scientific basis, and as clinical experience thus far has demon- 
strated the usefulness of milk prepared in this manner in the feeding of 
infants in a certain -proportion of cases, it will probably continue to be 
regarded as one of the best substitutes for breast-milk. It has also been 
found useful for children with feeble digestion, who have passed beyond 
the age of lactation. 

If for any reason cow's milk be not peptonized, an alkali added to 
• it retards coagulation, and tends to prevent the formation of large and 
thick curds. If therefore the child vomit curds, or pass fragments 
of them in the stools, lime water may be added, or the carbonate of 
sodium as recommended by Yogel, who dissolves one drachm of the 
carbonate in six ounces of water, and adds a teaspoonful to the milk at 
each meal. A more effectual way to prevent the formation of large 
and firm caseous coagula, is to mix with the milk some bland and easily 
digested farinaceous food, as Liebig's which, by mechanically separating 
the caseous particles, prevents the formation of large masses; and 
which, while it has nutritive properties, dilutes the milk and enables 
the digestive fluids to act more readily upon it. 

It is known that infants prior to the third month can digest only 
a very small amount of starch, since the salivary and pancreatic glands, 
whose secretions convert starch into glucose, a necessary change in 
digestion, are almost rudimentary in the first months of infancy. In 



liebig's food. 63 

a monograph relating to Infant Diet written by Professor A. Jacobi, 
and revised, enlarged, and adapted to popular reading by Dr. Mary 
Putman Jacobi, it is stated that the parotid glands which, together, 
weigh 80 grains at fifteen months, and 120 grains at two years, weigh 
but 34 grains at the age of one month. In several instances we 
weighed the pancreas taken from the bodies of infants who had died 
under the age of six months in the New York Infant Asylum. Its 
weight was very different in those whose ages were about the same ; in 
several under the age of four months it was less than one drachm, and 
in some more than one drachm ; but in no instance did it reach two 
drachms. The submaxillary and sublingual glands, which also secrete 
a liquid that is designed to convert starch into glucose, are compara- 
tively insignificant in young infants, so that the combined action of the 
parotid, submaxillary, sublingual, and pancreatic secretions, must be 
inadequate for the saccharification of the starch which ordinary farina- 
ceous food contains, during the first three or four months of infancy. 

But it is noAV ascertained that the salivary and pancreatic secretions 
are not the only agents by which starch is digested. The mucous 
surface furnishes an ' ' epithelial ferment, which assists in the change, 
so that the secretions from the buccal and intestinal surfaces materially 
aid in the digestion." (Revue des Sciences Med., 1879, by Charles 
Richert; also remarks by Professor Flint, Jr., in Physiol, of Man.) 

It appears, therefore, that young infants are able to digest a certain 
amount of starch, but a much smaller proportion than those who are 
older ; and the preparation of a farinaceous food in which saccharifi- 
cation of the starch is effected by a chemical process, and the delicate 
and easily deranged digestive organs of the infant relieved of the task, 
has long been a desideratum. 

The late Baron Liebig, who devoted considerable time in the last 
years of his life to the study of the food of infants, prepared such an 
article, widely and favorably known as Liebig's food. It is found in 
the shops bearing the names of the parties in whose laboratories it is 
prepared. The preparations of it in common use are Hawley 's, Horlick's, 
Mellin's, Keasbey k Mattison's, and the baby sup. As regards Keasbey 
& Mattison's, Horlick's, and Mellin's Liebig's food, chemical examination 
shows that in samples from the laboratories of these gentlemen the con- 
version of starch into glucose and dextrin is complete. 

The following statements indicate the nature of Liebig's food, and 
the way in which it is prepared. Starch is transformed into sugar and 
dextrin, a change which, when farinaceous substances are used in the 
usual way, is effected in the system, and thus the digestive organs are 
relieved from a part of the burden of digestion. 

"The following is the best way of preparing this food: Half an 
ounce of wheaten flour, and an equal quantity of malt flour, seven 
grains and a quarter of bicarbonate of potassium, and one ounce of 
water, are to be well mixed; five ounces of cow's milk are then to be 
added, and the whole put on a gentle fire. When the mixture begins 
to thicken, it is removed from the fire, stirred during five minutes, 
heated and stirred again, till it becomes quite fluid, and finally made to 
boil. After the separation of the bran by a sieve, it is ready for use. 



(i-i ARTIFICIAL FEEDING. 

By boiling it for a few minutes, it loses all taste of the flour." (London 
Lancet, January 7, 1865; Braithwaite' s Retrospect, July, I860.) 

This food, according to Liebig, furnishes double the amount of nutri- 
ment contained in milk; or, as he expresses it, is a "double concentra- 
tion" of that secretion. 

Dr. Hassell, in a communication in reference to this food to the Lon- 
don Lancet for July 29, 1865, says: "It appears to me that the great 
merit of Liebig's preparation consists in the use of malt flour as a con- 
stituent of the food; this, from the diastase contained in it, exercises, 
when the fluid or soup is properly prepared, a most remarkable influence 
upon the starch, quickly transforming it into dextrin and sugar, so that 
in the course of a few minutes the food, from being thick and sugarless, 
becomes comparatively thin and sweet." 

Liebig's food should be used with milk, in varying proportions accord- 
ing to the age of the child. Among the many foods found in the 
shops besides Liebig's, Nestle's should be noticed, since it is favorably 
mentioned by high authorities as Henoch, and is largely used with good 
results in many instances. It consists, as stated above, of wheat flour, 
yelk of egg, condensed milk, and sugar. One thousand parts contain 
twenty parts of nitrogenized matter and seven of salts. The samples 
which I have examined have been alkaline. Since it consists largely of 
Swiss condensed milk, no milk is to be added to it, and it is quickly 
prepared by boiling it a moment in nine or ten times its quantity of 
water. A list of the foods which have been found useful in infancy and 
childhood would be incomplete without mention of condensed milk. 

Condensed milk is largely used in the feeding of infants. The milk 
is condensed in vacuo to one-third or one-fifth its volume, heated to 100° C. 
(212° F.) to kill any fungus which it contains, and, when canned, 38 to 
40 per cent, of cane-sugar is added to preserve it. In the first month 
one part of milk should be added to fifteen of water, and the proportion 
of water should be gradually reduced as the infant becomes older. The 
large amount of sugar which condensed milk, preserved in cans, con- 
tains, renders it unsuitable in the dietetic role of the summer diarrhoea of 
infants. The sugar is apt to produce acid fermentation and diarrhoea 
in hot weather. Borden's condensed milk, freshly prepared, as dis- 
pensed from wagons, contains, I am informed by the agent, no cane- 
sugar or other foreign substance, and on this account is to be preferred 
to that in cans. It is cow's milk of good quality, from which 75 to 
79 per cent, of the water has been removed under vacuum. The 
chief advantage which it possesses — and it is an important one — is that 
it resists fermentation longer than ordinary milk. In not a few in- 
stances which have come to my notice, infants were found to do better 
when fed with condensed milk than with ordinary milk, or even pep- 
tonized milk, a fact readily explained by the absence of fermentation 
in it. 

The selection and preparation of the farinaceous food to be used in 
milk in the feeding of infants are important. It is better for young 
infants, as is seen from facts stated above, that the starch, or a part of 
the starch in their food, be converted into glucose before the admix- 
ture. This can be accomplished if a few pounds of wheat flour be placed 



RULES FOR ARTIFICIAL FEEDING. 65 

dry in a muslin bag, so as to form a ball, and boiled three or four 
days in water sufficient to cover it. The flour grated from it has the yel- 
lowish color of glucose, and gives a decided sugar reaction to Fehling's 
test. A small quantity of a good extract of malt, as Trommer's or 
Reicl and Carnick's, added to a tepid gruel of any of the farinaceous 
substances, also transforms the starch, so that it becomes thinner and is 
probably more readily assimilated by the infantile digestion; or one of 
the Liebig's foods described above may be used, in which the starch is 
converted into glucose. 

Meigs and Pepper, in their standard treatise, recommend for arti- 
ficially fed infants the admixture of prepared gelatine or Russian isin- 
glass with the milk, and they state that in their practice, extending 
over many years, infants "have thriven better upon it than upon any- 
thing else." A piece of gelatine two inches square "is soaked for a 
short time in cold water, and then boiled in half a pint of water until 
it dissolves — about ten or fifteen minutes." To this is added, with 
constant stirring, the milk, containing some farinaceous food. Others 
who have used food prepared in this manner speak well of it. Although 
gelatine contains little nutriment, its presence may aid digestion, and a 
food recommended by physicians of such experience as Meigs and 
Pepper is worthy of trial in cases of habitual indigestion, or of intestinal 
catarrh, in which the ordinary food disagrees. 

Milk should be the chief article of food during infancy, but the older 
the infant becomes, the larger should be the proportion of solid food 
given with it. After the first year the food may be made of such con- 
sistence as to be given with the spoon. In the second year and subse- 
quently, a pap may be made of stale bread boiled in water sufficient to 
cover it, and mixed with fresh milk, care being taken that all lumps are 
reduced to a pulp. Beef tea is a laxative, on account of the salts which 
it contains, as is also chicken tea ; but a small, or moderate, amount of 
it may be given once a day. Stale wheat bread or soda cracker should 
be crumbled in it and soaked, so as to be soft. If there be diarrhoea, 
the ordinary beef tea should not be allowed, on account of its laxative 
effect, but the expressed juice may be given instead. Few vegetables 
are proper for infants under the age of one year, but the potato, baked 
and mashed so as to be like flour, may be given at the tenth or twelfth 
month. It contains a large amount of starch, but appears to be readily 
digested by infants of the age mentioned, if given once a day in mod- 
erate quantity, with a little butter and salt added. In the second year 
a greater variety of food may be allowed, but the full diet of the table 
must not be given till after infancy, or at the age of three years. In the 
beginning of the second year the infant is weaned. He has twelve 
teeth, eight incisors, and four molars, which, with their broad surfaces, 
are designed for chewing. Let him have now, once or twice each day, 
in addition to the food which has previously been employed, a small 
piece of roast beef, rare done and cut very fine. Other meat, as 
mutton, may sometimes be given instead. After the age of eighteen 
months, light puddings of farinaceous substances, properly prepared, as 
of rice and corn meal, may be added to the dietary. 

All the teeth of the first set have appeared at the age of two years 

5 



66 BATHING, CLOTHING, SLEEP, EXERCISE. 

and five months, and the time has now arrived when a more marked 
transition may be made from liquid to solid food. Certain fruits may 
be allowed, even before this period ; as also the jellies of most berries, 
and of fruits, which being deprived of seeds and parenchyma are for 
the most part readily digested, while they give a relish to the farina- 
ceous food with which they are eaten. Pastries as ordinarily made, 
whatever fruits they may contain, are too rich and indigestible for 
young children. The following judicious rule for the preparation of 
fruits for children, copied in popular treatises on hygiene of infancy 
and childhood, is from Murray s Modern Cookery Book. ..." Put 
apples sliced, or plums, currants, gooseberries, etc., into a stone jar, 
and sprinkle among them as much Lisbon sugar as necessary ; set the 
jar in an oven or on a hearth, with a teacupful of water to prevent the 
fruit from burning ; or put the jar into a saucepan of water, till its con- 
tents be perfectly done. Berries and fruits thus prepared, and the fruit 
jellies, are best eaten spread on bread and butter, or on soda crackers." 



CHAPTEE IX. 

BATHING, CLOTHING, SLEEP, EXEKCISE. 

Bathing is now recognized in all civilized countries as one of the 
chief promoters of bodily comfort and health. The first bathing of the 
infant, which is immediately after birth, should be in water at a tem- 
perature a little below that of the blood, namely, at about 96°, after 
which the general bath is inadmissible until the navel string is detached. 
In the infant, reaction of the surface when chilled is tardy and uncer- 
tain, and therefore there is great danger of catching cold when the 
surface is cooled by water, and does not quickly react. It is a matter 
of daily observation that infants become chilly and their extremities re- 
main cool in a medium, whether air or water, in which older children 
and adults would have comfortable warmth. Therefore they are liable 
to contract bronchitis, sore throat, intestinal catarrh, or other inflam- 
mation, from very slight exposures. This fact must be borne in mind 
in considering the subject of bathing. 

During the first year after the detachment of the navel string, the 
bath should be employed daily, but not longer than three minutes ; 
during which time thorough ablution can be performed. Different 
authorities disagree in regard to the proper temperature of the bath 
during the first months of infancy. Steiner of Prague, a high authority 
in children's diseases, says, " During the first nine months the infant 
should have a daily bath a little above blood heat," . . . but most state 
a temperature a little below blood heat. In my opinion it should be 



CLOTHIXG. 67 

at 92°, which is considerably below blood heat, but which communicates 
a moderately warm sensation to the hand. After the age of ten months, 
or even of eight months for vigorous children, the temperature of the 
bath maybe reduced to 90°, and it should not be lower than this during 
the remainder of infancy, or if it be used a little lower, care should be 
taken to produce reaction by brisk rubbing and exercise, after a short 
bath. At the close of infancy, namely at two and a half years, the 
temperature may be still further reduced, but it should not, even for the 
most robust children of eight or ten years, be below 78°, which is re- 
corded on our thermometers as the temperature of summer heat, and is 
about that of our northern lakes during midsummer. 

The rules given in the books, not to bathe or direct a child to be bathed 
immediately after eating, or after much exercise, when the pores of the 
skin are perspiring, should be heeded. The head should first be wet 
with the water, and Castile soap should be applied over the surface to 
insure cleanliness. The strongly scented toilet soaps sometimes contain 
rancid fats, or other deleterious substances, and should be regarded with 
suspicion. In hot weather a daily bath is advisable, but in the cooler 
months it is sufficient if the child bathe twice or three times in the week. 
If, from lack of conveniences, or for other reasons, general bathing be 
dispensed with and the surface be washed from a basin or bowl, cooler 
water may be used than would be proper for the general bath, and a 
longer time to complete bathing would evidently be required. The bath- 
room should be comfortably warm, and after the bath the surface should 
be briskly rubbed with flannel, or, in case of older children, with a 
suitable coarse towel, and exercise afterward encouraged' to insure full 
reaction. In New York, in one of the largest and best managed asylums, 
both boys and girls are allowed to bathe, in bath-houses, in the Hudson 
when the water and weather are not too cool. 

It may be well to add to these general remarks on bathing the recent 
remarkable statement of a high authority on thermometric observations 
and temperature, that, during hot days, a bath in hot water, employed 
in the hours of greatest atmospheric heat, tends to reduce the heat of 
body and to preserve its normal temperature during the remainder of 
the day. ' Wunderlich says, " In tropical countries and in very hot 
seasons, no means of cooling is so lasting as a bath or douche of very 
warm water." 

Clothing. 

One of the most important duties of the mother or nurse is the 
selection of clothing for children which will be suitable for their age 
and the season. In the matter of dress, as in that of diet, many errors 
are unconsciously committed. In a room of proper temperature, which 
during the cool months should be 70° for infants and 68° for children 
old enough to run about, the head should never be covered unless in 
case of young infants ; but the sides of the head, as well as the neck 
and shoulders, may be lightly covered in sleep. It is the common prac- 
tice to leave off the "bellyband" which is applied after birth, when the 
infant has reached the age of three or four months; but, from the fact 



68 BATHING, CLOTHIXG, SLEEP, EXERCISE. 

that infants so often take cold, especially at night by throwing off bed- 
clothes, both in cool weather, when the temperature of the apartment 
may fall below 70°, and in summer, when there are currents of air 
through open windows, I advise the continuance of the band during the 
first year or eighteen months. In the summer it should be made of 
light merino, and in the winter of flannel. It should never be so thick 
and heavy as to be uncomfortable, or so snug as to interfere in the least 
with the free movements of the chest and abdomen in respiration. It 
should extend to and not over the ribs, and should be secured either 
with safety pins or a few stitches. If excoriations or prickly heat 
appear on the skin under the band in hot weather, a very common 
eruption in infancy, the surface should be dusted with subnitrate of 
bismuth, or a mixture in equal parts of lycopodium and oxide of zinc, 
and a single layer of linen should be applied over it and under the band. 
If the eruption be severe, it might be best to substitute a linen or soft 
muslin band for a time in place of the merino. 

A cardinal principle in the clothing of children is that the garments 
should always be so loose as not to interfere in the least with the func- 
tional activity of organs. The fitting and putting on of the dress is 
left too much to the discretion of the nurse, who is usually ignorant of 
the important facts in physiology, and unwittingly and with the best 
intentions injures her charge. I have often interposed to loosen the 
dress of young infants, which was so tight as sensibly to embarrass 
respiration ; and the case of a new-born infant has been reported to me 
in which it seemed probable that death resulted from this cause. Infants 
especially, who are so liable to pulmonary collapse and intestinal hernia, 
should have loose covering of both chest and abdomen. Pressure over 
the stomach always feels uncomfortable, and this organ, almost as much 
as the lungs, needs full expansion and free movement, in order to per- 
form its function of digestion properly. The same is true also of the 
intestines, but they tolerate compression better, and their movements 
are less impeded than those of the stomach by too tight dressing. 
Another part, where too snug an application of the dress does very 
great harm, is the neck, since moderate pressure in this region may 
retard the circulation of blood through very important vessels, namely, 
those wdiich supply the brain, or return blood from this organ. The 
dress about the neck should always be so loose that the four fingers of 
the nurse can be readily introduced underneath it. Skirts upon girls 
are sometimes supported by being tied tightly around the w r aist and over 
the stomach. This should never be allow T ed, but they should always be 
supported by shoulder straps, and be loose around the w r aist. 

Clothing protects the body according to its thickness and the feeble- 
ness of its conducting power of heat. Woollen, fur, and feather gar- 
ments have very low conducting pow T er, and wool, from its plentiful 
supply and cheapness, must always be the material w T hich is chiefly 
worn in the winter season; while cotton, and in still greater degree 
linen, are active conductors of heat, allowing its quick escape from any 
part of the body which it covers, and they are therefore the proper 
material for summer clothing. 

The color of a garment matters little as regards the escape of heat 



SLEEP. 69 

from the body, for whatever its color its surface next the body is neces- 
sarily dark from the exclusion of light; but the color is important as 
regards the absorption of heat from the atmosphere and the solar rays. 
Black has the highest absorptive power, while white has the least, and 
the mixed colors have absorptive powers which are intermediate. In 
experiments made with shirtings of different colors, while white received 
100° F., black received 208° F. A light color is, therefore, the best to 
dress children in during the hottest weather. 

The covering which is proper for the head of a child when outdoor, 
must evidently vary considerably in different seasons, and in different 
states of weather. Many a young child, with scanty growth of hair, 
has contracted that painful disease, inflammation of the ear, followed 
perhaps by a protracted discharge, and more or less impairment of 
hearing, in consequence of taking cold from insufficient covering of 
head and ears in inclement and changeable weather ; even leaving off 
accidentally a band or tie to which a child is accustomed will sometimes 
give it a cold. 

In this connection, I wish to call attention to the common and dan- 
gerous practice among the poor of allowing children to go bareheaded 
in the sun during the season when the atmospheric heat is highest. 
Not a summer passes in which I do not meet cases of inflammation of 
the brain, which I believe to be largely due to exposure to the sun's 
rays. There is no better and safer covering for the head of a child, 
who is allowed to go in the open air during the hot weather, than the 
light, cool, and inexpensive straw hat. 

The feet should always be warm and dry, the shoes worn in wet 
weather being water-proof; and special care should be taken in the 
selection of shoes, that they be pliable and loose, so as to allow freedom 
of growth, without compression of any part. If during the period of 
growth proper precautions are taken in this respect, the chiropodist 
would have little to do in subsequent years. Corns, bunions, and in- 
growing toe-nails originate from shoes hard and unyielding, or too 
tightly fitting. 

Sleep. 

The new-born infant requires from fifteen to eighteen hours' sleep 
each day. If it do not have this, and be wakeful, it is probably not 
well. It sleeps therefore most of the time when not awake for nursing, 
bathing, and change of clothing. As it grows older, a less and less 
amount of sleep is required. At the age of three years, about nine 
hours of sleep are needed, and it is better, for healthy development, to 
allow children of this age one or two hours of sleep in the middle of the 
day. They indeed often take it by falling asleep on the sofa, or floor, 
or in places where they are liable to take cold through currents of air 
and scant covering, if not heeded. 

Much harm has been done to children who were wakeful by nurses, 
and mothers too, who have given them active and dangerous drugs, as 
laudanum or morphine, under some enticing name as soothing syrup or 
cordial. A wakeful and fretful child is not well. Its ailment may be 



70 BATHING, CLOTHING, SLEEP, EXERCISE. 

trivial or grave, but it should never, under such circumstances, receive 
from mother or nurse any of those proprietary mixtures, having seduc- 
tive names, which the shops contain. If it need medicine, it should be 
examined and prescribed for by the physician. It is scarcely necessary 
to call attention to some accepted and important facts regarding the dor- 
mitory of children. A free ventilation is required, either through ven- 
tilators or open windows, and a sufficient number of cubic feet of air 
should be allowed for each sleeper. A small room should not contain 
more than two children. Curtains should not as a rule be employed, 
and no open vessels of foul water should stand in the room, or anything 
else which may contaminate the air. The garment worn through the 
day must be entirely removed and hung up away from the bed. 

In the asylums of New York, where from long and abundant experi- 
ence the management of children is systematized, infants and the 
younger children are usually put to bed between six and seven, and 
the older children between seven and eight o'clock ; the last meal or 
supper, as I have stated elsewhere, being light and easily digested. 



Exercise. 

Exercise is an important hygienic requirement. Harm often results 
from modes of exercise which are not adapted to the age. Occasionally 
I meet cases of permanent bow-leg, which have manifestly resulted from 
attempts to make infants stand at the age of four or five months. 
They should never be encouraged to walk or stand till about the age of 
one year, and if they do at the age of nine or ten months let it be volun- 
tary, and not taught by standing them upon their feet. In case of 
infants with rachitis, which disease is common in cities, and is char- 
acterized by a lack of lime-salts in the bones, and can be detected by 
great backwardness in teething, attempts to stand or walk for any 
length of time should be discouraged, till by the use of lime-salts and 
cod-liver oil, and improvement of the general health, the rachitis is cured. 
Much of the permanent deformity which mars the beauty and sym- 
metry of adult life originates in rachitis and might have been prevented. 

The infant before he is old enough to stand takes sufficient exercise 
in a way that is natural and harmless. Let him die upon his back in 
the crib, or on the floor, with a blanket under his body and pillow under 
his head, and all his clothes loose, so as not to restrain the free move- 
ments of his limbs. A healthy infant seems to enjoy this attitude, 
moving all his limbs sufficiently to give them the required exercise, and 
evincing his delight and exuberance of life by utterances which are as 
expressive as words. 

In the cool months of our latitude, infants should not be taken out- 
door until the age of three months, and then only for a brief time in 
the warmest part of the day ; but in the summer they should begin to 
receive outdoor air and exercise at the age of one month. In warm 
weather the face should never be covered by a veil or otherwise, and 
air and light should have free access to it. The rays of the sun, how- 
ever, from a clear sky, should be excluded either by a parasol or the 



APNCEA NEONATI. 71 

shade of trees or houses, or by the carriage in which the infant is car- 
ried. In cold weather, or when there is a strong wind, the protection 
of a veil is needed. Rude tossing of infants, which is common in 
families, should always be forbidden. Its effect on the cerebral circula- 
tion is likely to be bad, and it involves risk of a serious accident. In 
one instance to my knowledge, death resulted from injury received in 
this way. 

Walking, as it is the natural, so it is the best, exercise for the older 
infants and during the period of childhood. It promotes digestion 
when not carried to the extent of fatigue, and gives gentle exercise to 
all the muscles. The baby-carriage answers a useful purpose, when 
combined with walking. With the ordinary hired nurse it is safer for 
the infant to be taken out in this vehicle than in the arms, for if the 
nurse in careless walking should trip, great harm might result. In one 
instance which came under my notice convulsions and idiocy were plainly 
referable to the fall of an infant from its nurse's arms upon its head. 

The ordinary lawn sports of childhood, as croquet for both sexes, 
playing ball or quoits for boys, which are rendered more exciting by the 
spirit of rivalry, are also useful for muscular exercise and development, 
while they involve little danger. The swing affords a pleasant exercise, 
and with the propulsion required it gives gentle but efficient activity to 
most of the muscles. 

Many of the gymnastic exercises are too severe, involve too much 
risk of ruptured tendons, sprained joints, and even of dislocated or 
broken limbs. 

Among all the ingenious inventions to provide sports and pastimes 
for children, there are none better than gardening and farming, where 
facilities will alloAV it, conjoined with the ordinary household duties. 
The healthy and robust development of the farming population, their 
almost complete immunity from rachitic and scrofulous ailments, is at- 
tributable to their outdoor mode of life, and the many kinds of health- 
ful work which farm life requires. Such work is always in the 
highest degree beneficial for children old enough to participate in it, 
while it develops the habit of productive industry. 



CHAPTEE X. 

DISEASES OF THE NEW-BOEN. 

Apnoea (Asphyxia) Neonati. 

In the healthy infant, born under favorable circumstances, the two 
important functions of life, respiration and circulation, are established 
within the first minute. But it not unfrequently happens, in conse- 
quence of some unfavorable circumstance, that the heart and lungs 



72 DISEASES OF THE NEW-BORN. 

cease to act, and the infant at birth lies motionless as one dead. Some- 
times in these cases an occasional pulsation of the heart can be detected 
when the fingers press under the left ribs, but there is no respiration. 
According to the nature of the cause, the surface is exsanguine or 
cyanotic and livid. 

Causes. — These are various. The fault may be partly in the infant, 
from feebleness in its development ; but the common causes are com- 
pression of the cord during birth, from breech presentation or otherwise, 
and powerful, frequent, and long-continued uterine contractions, often 
induced by ergot, but sometimes occurring normally, which compress 
the placenta, and consequently obstruct the foetal circulation. Detach- 
ment of the placenta before birth, and protracted labor, from pelvic 
malformation or otherwise, even when there is no unusual severity of 
the pains, are occasional causes. 

Treatment. — Obviously the treatment must be prompt. Mucus 
should be removed from the mouth and fauces with the finger, and, 
except in those cases in which there has been placental hemorrhage or 
anaemia from other causes, as exhibited by pallor of the surface, a few 
drops of blood should be allowed to run from the cut extremity of the 
cord. The flow induced aids in establishing the circulation, and, in 
the large proportion of cases, in which there is congestion of the 
internal organs, gives partial relief to it. Brisk rubbing of the body, 
slapping of the buttocks, blowing in the face, sprinkling water upon it, 
alternately transferring the body from a tub of hot to cold water, may 
be tried in quick succession, and, if there be no signs of returning ani- 
mation, no time should be lost in resorting to artificial respiration. 

The child should be placed on its side upon the edge of a table, with 
a blanket underneath it, and the head in such a position that the epi- 
glottis falls forward ; a towel or napkin should be placed over its face, 
having a hole of sufficient size to blow through, corresponding with its 
mouth. The physician, compressing firmly the epigastrium with his 
thumb, blows a full breath through the hole. A little of the air, not- 
withstanding the compression, enters the stomach; some may escape 
by the nostrils, and the rest enters the lungs. Immediately the hand, 
passing from the epigastrium to the thorax, compresses it gently, though 
with sufficient force to produce expiration. This should be repeated 
six or eight times per minute. The action of the heart, previously 
slow, becomes quicker by the artificial respiration. I have been able 
to produce pulsations by this method when the heart had ceased to beat 
for a considerable time, and death, to all appearance, had occurred. 
Some recommend placing the infant on the right side, on account of the 
position of the valve between the auricles, but I think it is better to 
change it from one side to the other, in order to prevent congestions, 
which are so apt to occur when the circulation is imperfect. The cir- 
culation always commences sooner than respiration. The first respira- 
tions are mere gasps — not more than one or two per minute in cases of 
decided asphyxia — but as they become more frequent, they are also 
deeper. 

Artificial respiration should be continued fifteen or twenty minutes 
in cases in which no action of the heart can be detected, by pressing 



CAPUT SUCCEDAXEUM. 73 

the fingers under the ribs, when, if there be no signs of returning ani- 
mation, the case is hopeless. If there be any pulsation, however feeble, 
we should not cease in the attempt at resuscitation. Some prefer 
insufflation through a tube (as the segment of a catheter) introduced 
into the larynx, and pressure upon the thyroid cartilage so as to close 
the pharynx, instead of upon the epigastrium. The principle of treat- 
ment is similar, but the mode which I have recommended above I have 
found successful beyond expectation. Thus, in one case in my practice 
in which pulsation in the umbilical cord had ceased from ten to fifteen 
minutes before birth in consequence of its prolapse, I employed artificial 
respiration nearly a quarter of an hour before there was any appreciable 
pulsation, but by perseverance the circulatory and respiratory functions 
were fully reestablished, and the child lived and was vigorous. When 
respiration commences, insufflation may cease, but it is proper to aid 
the respiratory movements a little longer by compressing the thorax 
after each inspiration. Still, the physician may be disappointed in the 
result. In not a small proportion of cases the respiration continues 
gasping, and after a few hours, perhaps even a day, death ensues. I 
have made post-mortem examinations of several infants who have died 
under such circumstances, chiefly in the Nursery and Child's Hospital, 
about six from recollection, and have found considerable uniformity in 
the appearance of the viscera. Only a small portion of the lungs, 
sometimes almost none at all, was found inflated, even when the cries 
had for a time been strong, and extravasated blood, usually in consider- 
able quantity, lay upon the surface of the brain, evidently having 
escaped from the meningeal vessels, which were in a state of extreme 
congestion in consequence of the protracted or difficult birth. Menin- 
geal apoplexy, therefore, seems to me the chief cause of the ill-success 
attending our efforts to save those who are so far resuscitated as to be 
able to breathe. 

Recently Professor H. L. Byrd, of Baltimore, has recommended a 
simple mode of resuscitation. The physician places his hands under 
the middle portion of the back of the child, with their ulnar borders in 
contact, and at right angles to the spine. Extending his thumbs, he 
carries forward the two extremities of the trunk by gentle but firm 
pressure, so that they form with each other an angle of about 45° in 
the diaphragmatic region. Then the angle is reversed by carrying 
backward the shoulders and the nates. An assistant may aid by sup- 
porting the head. By alternating these movements, Professor Byrd 
has succeeded in effecting resuscitation when other methods had failed, 
and when so much time had elapsed that the case would seem hopeless 
to most practitioners. The name and position of Dr. Byrd commend 
this method to consideration and* trial. (American Supplement of Ob- 
stet. Journ. of Ghreat Britain and Ireland, 1873.) 

Caput Succedaneum— Cephalsematoma. 

During the birth of the child, extravasation of blood not infrequently 
occurs in the part of the scalp which presents. This results from the 
passive congestion, more or less intense according to the duration of 



74 DISEASES OF THE NEW-BORN. 

labor and severity of the labor-pains, which occurs in the presenting 
parts. Caput succedaneum is the term employed to designate the 
swelling thus caused when located upon the head. Its seat is the 
loose connective tissue of the scalp external to the pericranium. The 
tumor is soft, painless, and usually located upon the occiput. It consists 
partly of extravasated blood, but largely of serum which has transuded 
from the congested vessels before that degree of congestion required to 
effect the transudation of the corpuscles was reached. I have repeatedly 
had an opportunity to examine this tumor in still-born infants brought 
from the lying-in wards attached to the Nursery and Child's Hospital, 
and have found when it was slight that it consisted almost entirely of 
serum, but ordinarily when dissected it presented the appearance of a 
bruise, with a large proportion of serum, the blood and serum infiltrating 
the scalp to a greater or less distance beyond the appreciable limits of 
the tumor. Caput succedaneum requires no treatment. As it lies in 
the loose connective tissue of the scalp, its liquid permeates the open 
connective tissue in every direction, and is rapidly absorbed, while the 
tumor disappears. The subsidence of the swelling is usually complete 
within forty-eight hours. 

Occasionally blood is extravasated under the pericranium, detaching 
it from the bone. This occurs in connection with caput succedaneum, 
and is observed when the latter declines. The tumor thus produced is 
designated cephalsematoma. It is situated upon the occipital or parietal 
bone, near the posterior fontanelle. Its base, corresponding with the 
denuded bone, is circular or oval, and it rarely crosses a suture. In 
exceptional instances two cephalaematomata occur, located upon the 
occipital and one parietal or upon both parietal bones. The liquid, 
being surrounded by the firmly attached pericranium, does not escape 
into the surrounding tissues, as occurs in caput succedaneum, and is, 
therefore, more permanent. The tumor flattens slowly, and does not 
disappear till after several weeks. At the age of six months a slight 
prominence can sometimes be detected, indicating the seat of the tumor. 
As the pericranium elevated by the blood does not lose its vitality, it 
soon begins to produce bone, so that after some days a ring of new 
bone can be detected bv the finger surrounding; the base of the tumor, 
and on the inside of the detached membrane a layer of bone is pro- 
duced, thin at first and flexible, but gradually approximating the old 
bone, and becoming firmer as absorption occurs. 

Some time since, a specimen was presented by me to the New York 
Pathological Society, showing this accident and the mode of cure. The 
child died about two months after birth, and the blood constituting the 
tumor, which had been in great part absorbed, was completely incased 
by the old bone below and the new thin formation above. The cavity 
at length becomes obliterated, and there onty remains some thickening 
of that part of the cranium which corresponds with the location of the 
tumor. 

Meningocele, Encephalocele, Hydrencephalocele. 

This is the analogue of spina bifida. An opening exists at some 
point in the skull, through which the meninges, or meninges with brain 



13RA1X TUMORS. 



75 



substance, protrude. The deficiency is congenital, and the tumor 
exists at birth, or is noticed soon after. It is termed a meningocele, 
if only meninges protrude; an encephalocele if it contain brain sub- 
stance in addition to the meninges ; and a hydrencephalocele, if, in 
addition to the brain substance, the mass contain liquid in its interior. 

The most frequent site of these tumors is the occiput, where the pro- 
trusion occurs from an opening in or at the edge of the occipital bone. 
The next most frequent location is the naso-frontal region. Rarely 
they occur upon the temporal, parietal, and basilar portions of the 
skull. Ordinarily, the opening in the occipital bone, through which 
the protrusion occurs, is at the median line, or near it, anterior or pos- 
terior to the occipital protuberance. The opening, if in the anterior 
part of the occipital bone, may extend to the fontanelle ; if in the pos- 
terior part, it may extend to the foramen magnum. It may connect 
posteriorly through the foramen magnum with the cleft of a spina bifida. 
If the opening in the occipital bone be large, the tumor is also usually 
large. Prescott Hewitt cites a case in which it extended to the loins ; 
but so large a mass consists mostly of liquid, and is rare. An -occipital 
encephalocele contains brain substance from the cerebellum or posterior 
cerebral lobes, or from both. If the tumor upon the occiput be a 
hydrencephalocele, the liquid is from the posterior cornu of a distended 
lateral ventricle, or from a distended and dropsical fourth ventricle, and 
it occupies the interior of the tumor, the brain substance surrounding it. 



Fig. 4. 




If the tumor be in the frontal region, the protrusion usually occurs 
between the cribriform plate of the ethmoid bone and the frontal bone, 
and it appears externally between the nasal and frontal bones. Ex- 
ceptionally, the point of protrusion is between the lateral halves of the 
frontal bone. The anterior lobe or lobes of the cerebrum protrude in 
an encephalocele in this location ; if the tumor be a hydrencephalocele, 
the liquid is derived from the anterior corn use of the lateral A^entricles, 
As a rule, the frontal are smaller than the occipital tumors, and the 



76 DISEASES OF THE NEW-BORN. 

skin covering them is more frequently red and vascular, so as to present 
the appearance of vascular tumors. 

Exceptionally, the protrusion occurs from a fontanelle, or from the 
line of one of the sutures, so that it is seated upon the side of the skull. 
Cases are also on record in which the opening existed between the 
ethmoid and sphenoid bones, through the sphenoid, or between the 
sphenoid and its greater wing. Tumors in this location appear in the 
pharynx or mouth, or enter an orbit displacing the eye, or protrude 
through the spheno-maxillary fissure. The tumor, wherever it occurs, 
is usually an encephalocele or hydrencephalocele, the meningocele being 
rare. Its walls consist of skin, dura mater, and arachnoid, with in- 
tervening connective tissue. If the protrusion be at the base of the 
brain, of course the external covering of skin is lacking. In other 
locations the skin constitutes the external coat, and it may be tense 
and scantily covered with hair, or red and vascular. The interior of 
the sac is lined by the arachnoid and dura mater. These tumors, 
whatever the exact character of their interior, can be more or less 
reduced by compression, with a return of a part of their contents into 
the cranial cavity ; but such compression usually produces cerebral 
symptoms, as stupor, or fretfulness, vomiting, and strabismus. The 
following characteristics of the three forms of these tumors aid in their 
differential diagnosis : 

Meningocele. — Small at first, and remaining either small or of 
moderate size, fluctuation distinct, pedunculated, translucent, no pulsa- 
tion, tense on forced expiration, reducible. 

Encephalocele. — Small, base wide, no fluctuation,- opaque, or some- 
times translucent at the apex, distinct pulsation, enlargement by forced 
expiration, partly reducible, cerebral symptoms by compression. 

Hydrencephalocele. — Tumor usually large, often pendulous, and its 
surface often lobulated, pedunculated, fluctuating ; portions translucent ; 
pulsation absent or rare. It is seldom affected by pressure, and the 
patient is likely to be microcephalic from the escape of brain substance 
external to the cranium. 

These protrusions have been mistaken for various cysts, as cephal- 
sematoma, serous and sebaceous cysts, abscesses, vascular growths, 
and polypi. The fact that such errors in diagnosis have been made by 
various surgeons shows the importance of a thorough and careful ex- 
amination before operative measures are employed. 

Most patients with this deformity die in a few weeks or months. 
The prognosis depends on the size of the aperture, and the amount of 
protrusion. It is most unfavorable in hydrencephalocele, which is 
usually attended by deficiency of brain within the cranium, sometimes 
to such an extent that the patient is microcephalic, and early death un- 
avoidable. The hydrencephalic tumor is very liable to grow, and, after 
a time, rupture, causing immediate death in convulsions or collapse. 
In meningocele, if the aperture be small, the tumor may remain small, 
become isolated from the cranial cavity, and the patient may live for 
years. But of the three forms of the tumor, encephalocele is regarded 
as the most favorable, since it is usually small, and patients with it 
not unfrequently grow up to puberty. The prognosis in these tumors 



OPHTHALMIA NEONATI. 77 

is very similar to that in spina bifida, which varies according to size of 
the aperture and the amount and character of the protrusion. 

Treatment. — Those who have had experience with this tumor concur 
for the most part in the opinion that surgical interference should not 
be resorted to unless rupture be imminent. The mass should be pro- 
tected from abrasion, and that degree of pressure should be employed 
which can be tolerated without producing cerebral symptoms. It is 
proper to draw off the liquid of a meningocele, if it be distended and 
likely to rupture, and the tapping may be repeated, with exceptionally 
the result of a cure, or of rendering the tumor stationary. Mr. Holmes 
has injected the tumor with two drachms of a mixture consisting of one 
part of tincture of iodine and two of water, allowing it to remain. And 
Mr. Annandale has ligatured the mass in one instance, and effected a 
cure. In encephalocele and hydrencephalocele, support and moderate 
pressure should be employed, and in the latter some of the liquid should 
be removed by a small trocar if rupture be threatening. 



CHAPTER XI. 

OPHTHALMIA NEONATI. 

This disease occurs in two forms, namely, the catarrhal and blen- 
norrhoeal, and there are many cases which are intermediate. 

Causes. — These are not the same in all cases. Exposure of the 
infant's eyes soon after birth to a bright light, catching cold, the intro- 
duction of a little of the vernix caseosa under the eyelids in the first 
washing, smoke, dust, and irritating gases, coming in contact with the 
eyes, are recognized causes. Infants living in ill-ventilated and dirty 
apartments, having untidy clothing, with faces and bodies seldom pro- 
perly washed, and attended by dirty nurses, are more frequently affected 
than those in the better walks of life, and better cared for. The disease 
is more prevalent in asylums than in private practice, for in the former 
the antihygienic conditions which conduce to it more frequently 
abound. 

The term blennorrhceal is applied to ophthalmia neonati when it is 
attended by an exaggerated secretion of muco-pus. It commonly results 
from the introduction of a particle of infective matter under the lids, 
during birth or afterwards, by careless handling. The gonorrheal 
virus may be thus introduced, or the acrid secretion of a leucorrhoea. 
M. Kroner states {Paris Med., February 28, 1885) " that he found 
the specific gonococcus in sixty-three out of ninety-two cases of oph- 
thalmia neonatorum." When they were absent the disease was less 
severe, and not likely to produce destructive effects upon the eye. He, 



78 OPHTHALMIA NEON ATI. 

therefore, believes that the classification of the ophthalmia into severe 
and mild depends largely on the presence or absence of the specific 
gonococcus. 

Symptoms. Blennorrhoeal Form. — In the beginning the palpebral 
conjunctiva is observed to be red, a little swollen, and its cutaneous 
surface presents a faint reddish tinge. Light appears to be painful, 
and the child is fretful and sleeps but little; but the eye itself has its 
normal appearance. The progress of the disease, however, is rapid, 
and in twenty-four or thirty-six hours there is so much tumefaction 
that the upper lid extends over the lower, and it may be impossible to 
separate them sufficiently to obtain a view of the eye. The tumefac- 
tion is due to oedematous infiltration. The conjunctiva, both palpebral 
and ocular, now presents a deep red hue, is thickened and swollen, and 
numerous fine granulations appear upon it ; occasionally also flakes of 
very delicate pseudo-membrane can be observed in addition. There is 
an abundant production of pus of a creamy appearance, sometimes 
tinged with blood, which oozes out when the lids are separated. A 
critical period has now arrived, one which may involve the destruction 
of the cornea unless the case be promptly and judiciously treated. 
Indeed, the gravity of the disease relates chiefly to the state of the 
cornea, which up to the present time, notwithstanding the severity of 
the inflammation and the amount of surrounding infiltration, has re- 
mained transparent and apparently unaffected. But within another 
twenty-four hours the cornea may lose its polish, and grayish, opaque 
spots of softening appear upon it. Soon perforation occurs, the aqueous 
humor escapes, and the iris falls forward, closing the aperture and pre- 
venting further loss of the liquids of the eye. 

I have observed destruction of the cornea and loss of sight chiefly, 
first, in cases of true gonorrhoeal infection, in which there is the maxi- 
mum amount of inflammation and tumefaction, extending even over the 
malar bone and supraorbital ridge, with marked redness and elevation 
of temperature of the lids ; and. secondly, with a less degree of inflam- 
mation in those who were highly scrofulous. Attention, then, to the 
cornea is all-important, since it can usually be saved with proper treat- 
ment, although there may so much purulent discharge and oedema that 
it may be impossible to see it for several clays. Occasionally the cornea, 
instead of sloughing, becomes infiltrated to a greater or less extent, and 
ulcerates, but without perforation. As the patient recovers, cicatriza- 
tion occurs. 

The inflammation soon begins to decline. The swelling, heat, and 
redness of the lids and conjunctiva, and the granulations, gradually 
disappear, and recovery is complete, except so far as the cornea may 
have been injured. 

Catarrhal Form. — The inflammation is from the first of a mild grade, 
pertaining chiefly to the palpebral conjunctiva, with but a slight dis- 
charge of purulent matter, and with little swelling or increase of heat 
in the lids. Attention is directed to the complaint chiefly by the 
secretion which collects in the angles of the lids or upon their border. 
There may be slight intolerance of light, and ordinarily minute granu- 



OPHTHALMIA XEOXATI. Id 

lations appear upon the inflamed mucous surface. This form of the 
disease may disappear within a few days, or it may be protracted. 

Ophthalmia of the new-born is contagious, sometimes highly so. It 
commences on one side, and, without precautions, commonly within a 
few days extends to the other. 

Treatment. — As soon as the inflammation occurs, the opposite 
sound eye should be covered with a compress, kept in place by strips 
of adhesive plaster. This eye should be examined, however, once or 
twice daily, in order to detect the commencement of inflammation, and 
the bandage be reapplied. 

Catarrhal ophthalmia requires very simple treatment. Frequently 
bathing the lids with lukewarm water, or milk and water, so as to 
remove the secretion from between the lids, suffices in a large propor- 
tion of cases. In the severer cases, lead-water constantly or frequently 
applied to the exterior of the lids is useful. Among the poor, mothers 
ordinarily bathe the lids with breast-milk, and by this simple treatment 
effect a cure. If the inflammation do not soon abate by this treatment, 
a mild collyrium of one-fourth grain of nitrate of silver to one ounce 
of water should be applied between the lids and allowed to run under 
them. 

Blennorrhea! ophthalmia, on the other hand, requires prompt and 
judicious management. There is scarcely a disease in which delay is 
more disastrous. 

The frequent removing of the pus is very important, which confined 
in large quantity underneath the closely compressed lids, by its pressure 
and irritation increases greatly the danger of destruction of the cornea. 
Therefore, the lids during the height of the inflammation should be 
pressed apart every hour, so as to allow the pus to escape, and the space 
between the lids be freed from it by a camel-hair pencil or a pledget of 
finely picked lint. Warm water, containing boracic acid three grains 
to the ounce, should be gently thrown under the lids every two hours, 
to wash away pus and flakes of pseudo-membrane. 

Medicinal applications to the inflamed conjunctiva should, in most 
cases, be mild, but be frequently applied. I have used, in the treat- 
ment of purulent ophthalmia, as recommended by Professor Gross, a 
weak solution of corrosive sublimate applied every three hours between 
and under the lids, the pus, so far as practicable, having been first 
removed by the brush and syringe. The following is the formula, and 
the result has ordinarily been favorable : 

R . — Hyd. chlor. corros. . . . . . . . gr. j ; 

Aquae rosae ........ t ^ij ; 

Aquae ......... ^vj. — Misce. 

Now that bichloride of mercury has been found to be the most prompt 
and efficient germicide and antiseptic, the indications for its use in this 
disease are seen to rest on a sound therapeutic basis. In the proportion 
of one part to four thousand of warm water, which is nearly of the same 
strength as employed by Prof. Gross, and used every second or third 
hour, it soon diminishes the virulence of this form of ophthalmia. 

Still the beneficial result which I have observed from this collyrium, 



80 OPHTHALMIA NEONATI. 

was no doubt largely due to the frequent removal of the pus, the impor- 
tance of which cannot, in my opinion, be too strongly urged. In blen- 
norrhceal ophthalmia, during the active period of the inflammation, with 
hot and swollen lids, linen in single thickness, or two thicknesses, 
squeezed out of ice-water, or, better, removed from a cake of ice, and 
applied every five minutes when it begins to warm, aids materially in 
subduing the inflammation, every moment of which, when the lids are 
much swollen, involves danger to the delicate cornea. This measure, 
therefore, which requires diligence on the part of the nurse, should be 
insisted on. As long as the cornea retains its transparency and polish, 
the eye is safe, but, as stated above, it is often difficult to obtain a view 
of it for some days. 

The decline of the inflammation is gradual, but generally pretty 
rapid, yet several weeks may elapse before there is full restoration to 
the normal state. When the inflammation begins to abate, and the 
dangerous tumefaction has to a great extent subsided, a collyrium of 
one-fourth grain of nitrate of silver to the ounce will expedite the cure. 

Occasionally granulations remain upon the lids. If they do not 
diminish and disappear when the purulent inflammation has ceased, I 
would not practise excision, as recommended by Vogel, but, having 
everted the lids, apply a solution of nitrate of silver, five or ten grains 
to the ounce, to the granulations, each second day, and immediately 
wash away the solution by a camel-hair pencil with salt and water, and 
apply a little sweet oil before the lid is returned. If the granulations 
do not disappear with this treatment, they may be lightly touched with 
the smooth surface of a crystal of sulphate of copper, followed by the 
application of water and sweet oil. By this mode of treatment, em- 
ployed from the commencement of the inflammation, a large proportion 
even of the severest cases do well. 

Doctor 0. D. Pomeroy, oculist, has kindly favored me with the fol- 
lowing remarks relating to the treatment of this disease : 

" The first indication of treatment is thorough cleanliness. The eyes 
should be washed out with tepid water and salt — a drachm to the pint. 
This may be done every one, two, or three hours, according to the 
amount of discharge. The latter never should be allowed to remain in 
contact with the cornea long at a time, on account of its excoriating 
effect. A soft, old linen rag or soft sponge may be used to apply the 
salt water: an assistant separates the lids and the water is squeezed out 
of the sponge into the eye. A syringe is objectionable on many ac- 
counts ; one being that the poisonous matter may be thrown against the 
operator's eyes. Frequently the discharge may roll into stringy masses, 
requiring them to be wiped away by means of the soft rag. 

"If the attack be mild, I would be very slow to order astringents or 
stimulants. Atropine, one grain to the ounce, used three or four times 
daily, must always be prescribed in any case whatever, for the corneal 
lesions are the only ones we fear. Acid, carbol., two to four grains to 
the ounce, may be used several times a day with a view to stimulate the 
conjunctiva gently and destroy the poison. Binding up the sound eye 
is not much practised in infants ; it is difficult to keep the dressing on ; 
and it does not always protect the eye ; further, the second eye involved 



OPHTHALMIA NEONATI. 81 

is not, as a rule, as bad as the first one. After three or four days, if 
the discharge become very profuse, and the tissues have a relaxed look, 
astringents should be prescribed, but they should never increase the ir- 
ritation, and should decrease the discharge. Arg. nit., gr. ss to the 
ounce, may be used from one to four times daily. Aluminii et potas. 
sulph., gr. iv to the ounce, may be employed for the same purpose, very 
freely. Zinc, sulph., gr. j to the ounce, may also be used in a similar 
manner. After a week or ten days, if the lids still remain swollen, and 
there be a profuse discharge, the lids may then be everted and stronger 
applications made. Arg. nit., five to ten gr. to the ounce, may be 
brushed on every second day ; carefully wash with salt and water before 
returning the lid to its natural position. Alum in saturated solution 
may be used in a similar manner, or acid. tan. gr. xx to the ounce, or 
cupri sulphat. in ten gr. solutions. 

" If the remedy do good to the eyes, continue; if not, change to some- 
thing else, and do not, on any account, over-irritate the eyes. 

" Cold may be applied in the earlier stages with the tense, red, and 
swollen lids, and insufficient discharge, for one, two, or three days. 

" The rule is to use the cold sufficiently to keep down any excess of 
inflammatory action. This may be known by diminished redness, heat, 
and swelling, and improvement in the appearance of the discharge. 
Cold applied about half the time is a good rule ; for instance, keep it 
on from fifteen minutes to an hour, then leave it off for the same time ; 
be guided by the exigencies of each case. Scarification of either the 
ocular or palpebral conjunctiva may be performed if necessary in the 
earlier stage if there be much swelling. The source of the injury to 
the cornea is from interference with its nutrition in consequence of com- 
pression and retarded circulation of the conjunctival and episcleral 
vessels, caused by the swelling. In scarifying the ocular conjunctiva, 
the incision should radiate from the corneal margin outward, and should 
not be deep, but enough to cause pretty free bleeding. This should be 
encouraged by bathing with warm water. 

" WJien the cornea is threatened with necrosis or sloughing, we may 
meet the indication as follows : the scarification already mentioned 
exerts a favorable influence, but if the lids be much swollen, perhaps 
impossible to evert, and likely enough in a spasmodic condition pressing 
upon the cornea, we may perform a canthotomy — that is, pass a stout 
pair of scissors into the external canthus and divide the commissure by 
one resolute cut extending to the bone. The bleeding resulting is of 
service, but the power of the orbicularis to exert pressure on the eye- 
ball is temporarily broken, which is the main indication for the opera- 
tion. The cornea should be carefully observed daily to see that there 
is no haziness or commencing ulcer, or even any abrasion of the epithe- 
lium, for the latter is often the first sign f a commencing; ulcer. 

"In case the cornea be seriously involved, especially if the eyeball 
be too hard or tender to the touch, and the patient be suffering unusual 
pain, paracentesis of the cornea should be performed. Unless the 
operator be very skilful, a spring speculum should be used and a 
fixation forceps to keep the eye steady. The cornea should be pierced 
near its periphery, and the broad cataract needle should be passed into 



82 DISEASES OF THE UMBILICUS. 

the anterior chamber with its point well turned forward to avoid the 
lens. In this position it should be gently tilted, so as to make the 
wound gape, when the liquid slowly escapes ; hold in this position until 
most of the fluid is evacuated, then withdraw the needle slowly to 
prevent prolapsus of the iris. This operation may be repeated every 
day or two if necessary. In an epidemic of purulent ophthalmia in 
young children, at the New York Foundling Asylum, I at first had a 
few cases of perforated cornea, but being more on my guard, I examined 
subsequent cases very carefully; when on the first signs of corneal 
trouble I performed paracentesis and did not afterward have a single 
perforation. However, the most careful attention will not always 
prevent trouble. One day you may find the patient doing well, and on 
the next the cornea may be perforated. It is well to remember that 
this is a very fatal form of eye disease. 

"Abstraction of blood by leeches may also be practised. As a rule, 
however, this is not very frequently employed in young children. One 
leech may be used at about one inch from the external canthus, but 
frequently it should be removed before wholly filling, and the resulting 
hemorrhage may be stopped by pressure or styptics. Repetition of the 
leeching is rarely required; but the leech may be applied again in 
twenty-four hours if the hypersemia return. A membrane sometimes 
forms on the conjunctiva of the lid or globe, or both, which may or may 
not be true diphtheritic conjunctivitis. It is an open question where 
membranous conjunctivitis ends, and diphtheritic conjunctivitis begins. 
In either event stimulating applications must be interdicted, at least 
until the membrane becomes thrown off. In other respects the treat- 
ment is similar to what has already been laid down. In Europe diph- 
theritic conjunctivitis is very fatal to the eye. In this country, for 
some reason not well known, it does not seem to be so fatal, although 
in a bad case here the eye is usually destroyed. When the eyes have 
nearly recovered from an acute attack, a chronic conjunctivitis may re- 
sult, even passing into a granular conjunctivitis or a true trachoma, when 
stimulating applications to the lids may be used, including atropine 
drops as a collyrium if there should be any photophobia or corneal 
trouble. If the child be of good constitution, however, and the gen- 
eral health be carefully preserved, this latter sequel to the disease does 
not often occur." 



CHAPTEE XII. 

DISEASES OF THE UMBILICUS. 

When properly managed, the cord desiccates and falls off between 
the third and ninth days. The nurse should not be allowed to oil it, 
which she will sometimes do unless forbidden, as this retards desicca- 
tion. If the dressing of the cord be allowed, to remain wet from the 



THROMBOSIS AND PHLEBITIS. 83 

-urine or otherwise, it does not desiccate, but decomposes. This is not 
infrequent in poor, intemperate, and slovenly families. The decaying 
cord is apt to produce inflammation of the navel. Some Southern 
physicians, prior to the late war, attributed the prevalence of trismus 
neonatorum among the slaves to the lesion of the navel produced by this 
cause. 

Thrombosis and Phlebitis of the Umbilical Vein, Septicaemia of 

the New-born. 

When the cord is ligated at birth, a considerable part of the blood 
in the umbilical vein flows away and enters the systemic circulation, 
but that which remains forms small clots or thrombi. These clots con- 
tract and harden, becoming in time calcified, and remaining inert and 
harmless in the system, or they may soften and dissolve. The ductus 
arteriosus, as I have frequently noticed at autopsies, and probably 
also the ductus venosus, are likewise occluded by fibrinous plugs when 
at birth they no longer participate in the circulation. But, so far as 
known, thrombi forming in these central vessels of the foetal circulation 
do no harm and have no pathological significance ; whereas those in the 
umbilical vein sometimes entail serious consequences, and even death. 
The entrance of air into the umbilical vein from the umbilical fossa, 
carrying with it germs from an infected atmosphere, may afford ex- 
planation of the serious disease long known under the designation of 
umbilical phlebitis. 

The remarks of Prof. Ziegler, of Tubingen, on the issues of throm- 
bosis, will aid to an understanding of the nature of this disease. He 
states the fact that the history and behavior of thrombi differ in 
different instances. In some cases he says that " the fibrin is trans- 
formed into a dense mass, which may persist unchanged for a long time, 
and ultimately becomes calcified. It is thus that the chalky concretions 
called phleboliths are formed in the veins. The very common issue of 
thrombosis in softening is much less favorable. In simple or red soften- 
ing the central parts of the thrombus are first of all changed into a 
grayish or reddish pulp, consisting of broken-down and shrunken red 
corpuscles, pigment granules, and colorless granular detritus. If the 
softening then extend to the surface layers, and if the blood current is 
still flowing over the thrombus, the products of disintegration may be 
carried into the general circulation. . . . The result is the formation 
of emboli. The most unfavorable issue of all is the 'puriform or yellow 
softening of the thrombus. In this case the thrombus is transformed 
into a dirty or reddish-yellow, fetid, pus-like cream or pulp. This 
contains a multitude of pus corpuscles, and a large proportion of a 
finely granular matter, which consists in part of fatty and albuminous 
detritus, and in part of micrococci. The latter frequently form groups 
or colonies, and are probably to be regarded as the exciting cause of 
the .softening process. Such puriform thrombi act destructively on the 
surrounding tissues and set up inflammation. The intima of the vessel 
becomes turbid or opaque ; and suppurative inflammation begins in the 
tunica media and tunica adventitia, extending to the tissue enclosing the 



84 DISEASES OF THE UMBILICUS. 

vessel. Soon the entire thickness of the vessel-wall is infiltrated, and 
takes on a dirty yellowish or grayish appearance; ultimately the tissues 
undergo putrid degeneration. If the puriform matters are carried by 
the blood current to distant spots, they there produce necrotic or putre- 
factive changes in the tissues, and set up suppurative inflammation." 

Puriform or yellow softening of the thrombi in the umbilical vein, 
occurs in those cases of inflammation of this vessel, which are attended 
by symptoms indicating general septic poisoning. This disease is usually 
fatal in the new-born ; it has long been known and described, but its 
pathology has been obscure. The concise and clear description of the 
yellow softening of thrombi, quoted above from the Tubingen professor, 
enables us to understand its nature. It will be observed that he con- 
siders the introduction of micrococci into the thrombus as the cause 
of the destructive changes which follow. It would seem an easy matter 
for micrococci to enter the umbilical vein from the umbilical fossa, and 
it is perhaps surprising, in view of the perviousness of this vessel, that 
this accident is not more frequent. The following were examples of 
inflammation of the umbilical vein, and of septic infection, resulting 
from the phlebitis : 

Case 1. — In May, 1884, an infant died in the New York Infant Asylum, 
having the following history : It was born after a natural labor, and there 
was no evidence of septic infection in the mother. The cord dropped on 
the seventh day, and the resident physician stated that the umbilicus ap- 
peared raw, and a slight oozing of purulent liquid occurred from it, show- 
ing its perviousness. My attention was not called to the infant until near 
its death, when I learned from the nurse that it had been very fretful 
during the last week, and recently the abdomen had become so distended 
and hard, that the physician of the asylum had diagnosticated peritonitis. 
Pressure upon the abdomen seemed painful, and an examination of other 
parts gave a negative result. The rectal temperature at this time, within 
two days of its death, was 102.4° ; the day before, it had been 100.6°. 
Death occurred on the morning of the fifteenth day. 

The autopsy was made twenty-six hours after death, by Prof. W. H. 
Welch. Six ounces of turbid serum were removed from the abdomen, 
containing yellowish flakes of fibrin. In the vicinity of the umbilical 
vein, and upon the under surface of the liver, especially along its trans- 
verse fissure, the peritoneum was covered by fibrin ; no marked congestion 
of peritoneum ; a number of lymphatic vessels filled with pus could be 
seen under the peritoneal covering of the diaphragm, showing in what 
way septic infection extends along the lymphatics. The lymphatics of the 
diaphragm open upon the pleural surface, and it is probable, had the 
patient lived longer, that suppurative pleuritis would also have occurred. 
The umbilical vein was filled from the navel to the transverse fissure of 
the liver with a gravish softened detritus, consisting of broken-down 
thrombi, with a considerable proportion of pus. Softened thrombi could 
be traced the entire length of the umbilical vein, the walls of which were 
.infiltrated and thickened from inflammation. No thrombi were seen in 
the portal vein or vena cava. Under the endocardial lining of the heart 
hemorrhagic points could be seen. The pericardial cavity contained more 
than the normal quantity of serum, with a few flakes of fibrin. The 
bronchi contained brownish mucus, and hemorrhagic spots were observed 
in the posterior portions of the lungs ; no evidence of pneumonia ; pan- 



THROMBOSIS AND PHLEBITIS. 85 

creas, suprarenal capsules, ovaries, and uterus normal ; ecchymotic spots 
under the peritoneal covering of the kidneys, and under the mucous mem- 
brane of the calices. 

It is probable that in this case septic micrococci played the im- 
portant part in producing the many lesions, evidently of a septic nature, 
which were present. These organs entering the lymphatics, and per- 
haps carried along in the bloodvessels, find lodgement in various parts 
of the system, where they produce inflammatory or septic lesions, with, 
in most instances, a fatal result. 

Case 2. — This infant at birth weighed eight pounds six ounces. It was 
plump and well developed, and the mother seemed healthy. When four 
or five days old it began to be feverish, one day the temperature rising to 
104|- D . The cord separated at the usual time and the umbilicus seemed 
healthy. At the age of two weeks an abscess appeared upon the scalp, 
one upon the back, and another upon the nates, indicating septic infec- 
tion. These abscesses remained and new ones appeared as long as the 
child lived. At the age of four weeks orchitis on one side occurred, and 
continued for three weeks, when it abated. When the child was two 
months old a prominence appeared half an inch above the umbilicus, and 
when it had continued about one week, the resident physician punctured 
it, and bile instead of pus escaped. The opening closed soon afterwards, 
and, subsequently, a discharge of bile occurred from the umbilicus, 
which continued until death. The infant gradually wasted and became 
weaker, and finally died at the age of eight months. 

Autopsy, by Prof. Welch. Infant much emaciated ; its length twenty 
inches; the remains of old abscesses upon the trunk and extremities; 
an abscess on the right side of the occipital bone contained four 
drachms of pus, underneath which the occipital bone was carious over an 
area of one inch by half an inch. The dura mater below the carious 
bone was thickened, but the pia mater was normal. A probe passed 
from the umbilicus into and along the umbilical vein. The umbilicus 
seemed normal, except a small cicatrix at its site ; heart normal ; lower or 
depending portions of the lungs, the spleen, kidneys, suprarenal capsules, 
and bladder presented the appearance of passive congestion ; stomach and 
intestines normal ; tunica albuginea of the left testicle thickened. The 
umbilical vein was dilated to about twice its normal size, its walls were 
infiltrated and thickened, and it contained yellow thickened bile. One 
of the branches of the vein traced into the liver opened into an abscess 
about the size of a walnut, and containing thick pus, and through this 
abscess a communication had been established between the umbilical 
vein and the bile-ducts. The gall-bladder and the hepatic and cystic 
ducts contained bile and appeared normal ; and the liver, except for the 
abscess, presented the normal appearance. The abscess was in the right 
lobe, near its posterior border, and it extended to the superior surface of the 
liver. The umbilical vein contained bile, with perhaps some bile-stained 
pus, but no blood ; peritoneum, brain, spinal cord, and meninges normal. 

Thrombosis of the umbilical vein, when the thrombi undergo putre- 
factive changes, is, as is seen by the above cases, one of the most severe 
and fatal maladies of the new-born. Disintegrating particles of fibrin 
loaded with micrococci may enter the circulation, and intercepted in 
distant organs cause embolisms. More disastrous still is the septic 



86 DISEASES OF THE UMBILICUS. 

infection of the system, such as occurred in the above cases, and which, 
as a rule, ends in death. 

Treatment. — Little can be done to stay the fatal progress of the 
disease when putrefactive decomposition of the thrombi has occurred. 
We may endeavor to press from the vein into the umbilicus the par- 
ticles of disintegrating fibrin, and perhaps we can in some instances 
inject into the vein a mild antiseptic liquid, as boracic acid in glycerine. 
But the results of such treatment would be uncertain and probably 
futile. Precautionary measures, especially antiseptic dressing of the 
umbilicus, as by dusting it with iodoform, might, if generally practised, 
diminish the number of these cases. 



Inflammation and Ulceration of Umbilicus. 

Inflammation of the umbilicus sometimes occurs in the new-born 
about the time of the detachment of the cord, or soon after. It probably 
results from uncleanliness, or carelessness in the management of the 
cord, by which irritating and decomposing substances remain in the 
umbilical fossa. Sometimes decomposing particles from the cord are the 
probable irritant. This disease is also most liable to occur in cachectic 
infants, or those of scrofulous parentage, whose general condition ren- 
ders them liable to inflammations. The umbilicus becomes red, slightly 
swollen, and moist by a secretion. Often the inflammation remains two 
•or three days in this mild form, receiving no treatment except from the 
nurse, and disappearing by the use of the dusting powder, as lycopo- 
dium, which she employs. In other instances, it extends over a radius 
of an inch or even more, the walls of the umbilicus become swollen and 
infiltrated, and ulceration succeeds. The ulcer is circular, occupying 
the site of the navel, and is attended by a purulent discharge. The 
inflammation may now gradually abate, and the ulcer heal with a 
cicatrix in place of the umbilicus. But in other instances, especially if 
there be decided cachexia, the ulcer extends in breadth and width, till 
finally, in the worst cases, the peritoneum becomes involved, and per- 
foration or peritonitis occurs, with death. 

Under unfavorable hygienic circumstances the blood of the infant 
being vitiated, the ulcer may become gangrenous; or the inflammation 
may terminate directly in mortification, without the formation of an 
ulcer. In either case the prognosis is unfavorable. If a dark brown 
slough occupy the site of the umbilicus, and a sero-sanguineous discharge 
exude from underneath, the common result is perforation, peritonitis, 
and death in from one to two weeks. 

Treatment. — Inflammation of the umbilicus, if severe, and espe- 
cially if attended by destruction of the tissues involved, rapidly reduces 
the strength. In such cases four or five drops of brandy should be 
administered every hour to two hours in the breast-milk. 

In the simple inflammation the navel should be bathed with lukewarm 
water three or four times daily, and the ointment of the oxide of zinc 
be constantly applied ; or if there be little or no discharge, the navel 
may be dusted with powdered bismuth. In case of ulceration the 



UMBILICAL HEMORRHAGE. 87 

navel should be gently washed three or four times daily with lukewarm 
water, to which carbolic acid is added — three or four drops to the ounce ; 
and if there be much inflammation, a light poultice of pulverized slip- 
pery elm should be applied in the interval, or if the inflammation be 
moderate, the balsam of Peru. If gangrene supervene, the parts 
should be frequently bathed with carbolic acid water, and a cloth soaked 
with it applied over them, or iodoform should be constantly applied. 
The slough should be detached as soon as it is so far separated that its 
removal causes no hemorrhage, after which the treatment for ulceration 
is appropriate. 



Umbilical Granulations or Fungus. 

When the cord falls, granulations sometimes sprout out from the ex- 
posed raw surface, and complete cicatrization is impossible till they are 
removed. They form a rounded mass of pale reddish hue, at the 
centre of the umbilical fossa, bleeding when rubbed, and causing con- 
stant moisture of the umbilicus. The largest which I have seen had 
perhaps twice the size of a large pea, and they may be of any smaller 
size. 

Treatment. — By pressing upon the umbilical parietes the tumor 
rises from the fossa, so that a silk ligature can be applied around its 
base, when the mass can be readily moved with the scissors. If the 
granulations be small, they may be removed by the scissors without the 
ligature, and hemorrhage prevented by touching the surface with lunar 
caustic. 



CHAPTEE XIII. 

UMBILICAL HEMOKKHAGE. 

The granulations which have been described above occasionally cause 
considerable hemorrhage when injured. The profuse and even fatal 
hemorrhage which occurs at birth, or soon after, from too loose a liga- 
ture of the umbilical cord, or from laceration or other injury, is so well 
known, and its cause so apparent, that it need only be alluded to in this 
connection. Bouchut details a case in which death occurred even be- 
fore birth, from this form of hemorrhage. The child was attached to 
the placenta by a very short cord, which prevented delivery till it parted 
by the traction of the forceps. The bleeding from the umbilical vessels 
was so profuse, that the child was pallid and lifeless when born. 

There is another form of umbilical hemorrhage, cases of which have 
been from time to time observed for more than a century (one of the 
first on record was reported in the Gentleman s Gazette, April, 1752, 



88 UMBILICAL HEMORRHAGE. 

by Mr. Watts, a physician in Kent, England), but little was done to 
elucidate its nature till three American physicians made it the subject 
of careful study, and the monographs which they have published upon 
it are the best which the literature of the profession affords. Dr. 
Francis Minot read his paper, containing the statistics of 46 cases, be- 
fore the Boston Society for Medical Improvement, in April, 1852. 
Prof. Stephen Smith prepared his paper, containing the statistics of 79 
cases, for the New York Statistical Society, in 1855. It was published 
in the New York Journal of Medicine for that year. Dr. J. Foster 
Jenkins presented his monograph as a report to the United States 
Medical Association in 1858, and it was published in the Transactions 
of the Association for that year. This paper is very valuable on 
account of its statistics, as the writer succeeded in collecting the records 
of 178 cases from medical journals, and gentlemen of the Association. 
These three papers contain nearly all that is known in reference to this 
disease. 

Sex — Age.- — Females are less liable than males to this hemorrhage. 
In Jenkins's cases, 34J per cent, were females, 65f males. The fol- 
lowing table gives the age at which the hemorrhage commenced in 99 
cases : 

Age. Xbs. 

Under 1 day .... 5 

Under 2 days 7 

Under 3 " 6 

Under 4 " 3 

5 to 7 " (inclusive) 32 

8 to 10 " " 25 

11 to 15 " " 16 

16 to 21 « " 4 

56 « . 1 

99 

Ordinarily the bleeding commenced very soon after detachment of 
the cord, but in not a few the cord was still adherent. 

Causes. — The common proximate cause is feeble coagulability of the 
blood. In the normal state, when the cord is ligated, the fibrin of the 
blood, w T hich now ceases to How in the umbilical vessels, forms coagula 
so firm that, by the time the cord is detached, hemorrhage is impossible. 
But in the majority of those affected with this disease, the clots are so 
soft and loose that they do not present any effectual barrier to the pres- 
sure of blood, which therefore oozes through them or presses them away. 
This lack of coagulability is easily demonstrated, for if a little blood, as 
it escapes, be caught in a vessel, it will be found to remain liquid a long 
time. This dyscrasia, or morbid state of the blood, which we therefore 
recognize as a chief cause of the hemorrhage, does not have the same 
origin in all cases. It is sometimes due to inherited syphilis. The 
infant affected with it may be plump, and appear well at birth, but in 
most instances, when the hemorrhage is to occur, it is puny and 
cachectic, exhibiting also local manifestations of the disease or cachexia 
from which it suffers. Thus, in a case in my practice, the infant, puny, 
and apparently born before term, was observed to have several blebs of 



UMBILICAL HEMORRHAGE. 89 

pemphigus on the first day, from some of which blood soon began to 
ooze, but the fatal umbilical hemorrhage did not commence till after 
two weeks. 

In about one-fifth of the cases ecchymoses or petechiae have been 
observed upon various parts of the surface, affording additional proof 
of the general blood disease. 

Jaundice is another cause of impoverishment of the blood in the new- 
born, and therefore of umbilical hemorrhage. The writers who have 
collected records of the hemorrhage, all remark the frequent occurrence 
of the icteric hue, both before and during the bleeding. It is not im- 
probable that, in certain instances, the jaundice is hnematogenous, arising 
from destruction of the red corpuscles and liberation of the hsematin, a 
not unusual result of a profound dyscrasia, whether syphilitic or origi- 
nating from some other cause. But in other, and probably most in- 
stances, the jaundice proceeds from the liver, and is the cause of the 
change in the blood. Thus, in five of Jenkins's cases, there was occlu- 
sion of the hepatic or common bile-ducts, and jaundice, from the presence 
of biliary acids in the blood, causes diminution in the amount of fibrin 
and red corpuscles. In the ordinary form of icterus neonatorum, the 
cause of which some suppose to exist in the relative fulness of the 
capillaries and minute bile-ducts in the acini of the liver, destructive 
blood changes probably occur in proportion to the degree and duration 
of the jaundice, and hence the tendency to hemorrhage observed in 
some of these cases. 

Poor health of the mother, and impoverishment of her blood during 
gestation, whether from chronic disease, as tuberculosis, or antihygienic 
conditions, also cause impoverishment and increase the fluidity of the 
blood of the child, and are therefore causes of the hemorrhage. The 
excessive use of diluent drinks or alkalies by the mother is believed by 
some to have a similar effect. 

In certain cases the hemorrhage is due to an inherited hemorrhagic 
diathesis. In nine of Jenkins's cases the mothers were subject to menor- 
rhagia, and liable to bleed freely after parturition, and from injuries ; 
and seventeen other mothers had each lost more than one infant from 
umbilical hemorrhage. Probably in those cases in which the hemorrhage 
commences before detachment of the cord, and external to its point of 
insertion, the hemorrhagic diathesis is the main cause of the flow. 

Although the cause of umbilical hemorrhage in the majority of cases 
is the vitiated state of the blood itself, observers, among others the late 
Sir James Y. Simpson, have met cases in which the hemorrhage was 
referable to the state of the vessels. In order that the vessels be 
effectually closed by the fibrinous coagula, their walls should have their 
normal contractility, but this is in great part lost by inflammation 
(arteritis or phlebitis) which sometimes occurs in these vessels, as we 
have already seen. Inflammation, whether of artery or vein, causes 
thickening and infiltration of its parietes, loss of tone on the part of the 
fibres of which they are composed, and therefore a patulous state of the 
vessel. 

Symptoms. — Ordinarily umbilical hemorrhage occurs without any 
premonition, but sometimes it is preceded by jaundice. Jenkins ascer- 



90 DIAGNOSIS OF INFANTILE DISEASES. 

tained that jaundice was a prodromic symptom in 41 out of 178 cases, 
and besides the icteric hue, constipation, clay-colored stools, deeply 
tinged urine, etc., were sometimes recorded. Rarely colicky pains and 
vomiting preceded the hemorrhage. The blood may be arterial or 
venous, or both. It oozes slowly or rapidly, rarely escaping in a jet, 
even when there is reason to believe that it is arterial. 

Prognosis. — This is unfavorable. Statistics show that five in every 
six perish. The prognosis is most unfavorable when jaundice or pur- 
pura hemorrhagica is present. Those are most likely to recover who 
have a healthy parentage, no obvious dyscrasia, and in whom the 
hemorrhage occurs late, and is not profuse. The average duration of 
the hemorrhage in 82 fatal cases in Jenkins's collection was three and a 
half days, the minimum being only three hours. After the arrest of 
the hemorrhage, death may occur from exhaustion or the dyscrasia. 

Treatment. — The treatment should be both constitutional and local. 
It is important, so far as time will permit, to treat the dyscrasia, and 
as the stools are frequently constipated, a laxative is often indicated. 
A laxative is not only useful for its effect on the hepatic circulation, but 
as a derivative. Both Smith and Jenkins recommend calomel for this 
purpose. The modes of treating the bleeding parts have been various. 
Those most deserving of mention are the following: injecting a styptic 
into the open vessels, applying a styptic by compress or sponge to the 
navel, covering the navel with dry or wet plaster of Paris, constant 
pressure with the finger, which is tedious, but which maternal solicitude 
willingly provides, and lastly, the use of needles with ligature. All of 
these methods have been more or less successful in arresting the hemor- 
rhage, but the last is most effectual, though painful. Two needles should 
be passed through the umbilicus at right angles, and a waxed thread 
wound around each in the form of the figure 8. In four or five days 
the needles should be removed, and a poultice or simple dressing applied. 



CHAPTEE XIV. 

DIAGNOSIS OF INFANTILE DISEASES. 

General Observations. 

Diseases in early life differ in important particulars from those oc- 
curring in maturity. Some which are common in the former age are 
unknown or are rare in the latter, and those which occur equally at all 
ages often present peculiar symptoms and a peculiar clinical history in 
the young. Therefore physicians who are skilful in treating adults, 
may be unskilful in treating children. Excellence as a physician of 



FEATURES, ETC., IX DISEASE. 91 

children can only be achieved by special and continued study of their 
ailments. 

Again, as regards the disease of infancy, in which period there are a 
great amount of sickness and a large mortality, diagnosis must evidently 
be made from the objective symptoms; from examining the features, 
attitude, utterances, the pulse, respiration, etc., and inspecting the 
surfaces, so far as they are accessible to view, and the eliminated pro- 
ducts. We lack for this age the important information which speech 
affords. Some general remarks, therefore, in reference to the appear- 
ances and functions of the system in early life, and the changes which 
they undergo in various pathological states, seem requisite, in order to 
a clearer appreciation of the symptoms, and more ready diagnosis of 
individual diseases. 



Features, External Appearance of Head, Trunk, and Limbs 

in Disease. 

In the new-born, as soon as respiration and the new circulation are 
established, the cutaneous capillaries become distended with blood, and 
the skin presents a congested appearance. By the close of the first 
week this external hyperemia begins to abate, and is soon replaced by 
the normal capillary circulation. 

Icterus is common in the first and second weeks. Bouchut attributes 
it to mild hepatitis. A much more plausible view of its causation, and 
probably the correct one, is that of Frerichs, who attributes it to the 
effect on the hepatic circulation of ligation of the umbilical cord. By 
ligation the current of blood through the umbilical vein to the liver 
ceases, the amount of blood in the hepatic capillaries, which connect 
with the branches of the vein, diminishes, and then, according to 
Frerichs, by the law of diffusion, diversion occurs of a part of the bile 
from the hepatic cells into the capillaries, while the rest flows in the 
normal manner into the bile-ducts. The degree of jaundice is pro- 
portionate to the amount of bile which enters the circulation. Icterus 
neonatorum is ordinarily not a disease of importance. If the general 
health remain good, it subsides without medicine in the course of one 
or two weeks, when the circulation through the liver becomes equalized 
and regular. 

The surface, or portions of the surface, of the new-born often present 
for a few hours a livid color, due to the mode of delivery. Protracted 
lividity occurs from atelectasis or malformation in the heart or great 
vessels ; lividity induced by exertion or excitement, while the respira- 
tion is normal, indicates malformation of the heart or vessels ; tempo- 
rary lividity sometimes occurs in severe acute diseases, especially those 
of the respiratory organs ; lividity, whether temporary or permanent, 
is a sign of imperfect decarbonization of the blood. 

The cheeks of children are congested in febrile and inflammatory dis- 
eases, except in a cachectic or prostrated state of the system. Transient 
circumscribed congestion of the face, ears, or forehead constitutes a 
reliable sign of cerebral disease. Strabismus occurring in connection 



92 DIAGNOSIS OF INFANTILE DISEASES. 

with febrile reaction, oscillation of iris, inequality of pupils, and drooping 
of upper eyelids, also denote cerebral disease. The pupils are contracted 
during sleep ; evenly dilated in death. 

Dilatation of the alae nasi during inspiration, with contraction of the 
eyebroAvs and a countenance indicative of suffering, attends severe in- 
flammation of the respiratory organs. Absence of tears during the act 
of crying shows a severe and probably fatal form of disease in infants 
over the age of four months. 

Rapid wasting of the features, causing deep suborbital depressions, 
prominence and pointedness of the cheek-bones and chin, and hollow- 
ness of the cheeks, are signs of severe diarrhoeal malady ; the most 
striking examples of this sudden collapse of features are afforded by 
patients affected with cholera infantum. In severe cases of this disease 
the physiognomy, from a state of fulness and health, presents in a few 
hours such a wasted and senile appearance that the friends with diffi- 
culty recognize the features with which they are familiar. Muscular 
tonicity is also greatly impaired in this disease, that of the orbicular 
muscles of the lips and eyelids to such an extent that the mouth is 
open and the eyeballs exposed during sleep. Great emaciation occur- 
ring gradually, is a symptom of subacute or chronic disease of a grave 
character, often of tuberculosis or chronic entero-colitis. 

Strabismus sometimes occurs in children who have no serious disease. 
It is then due to simple paralysis of one or more of the motor muscles 
of the eye. But when supervening upon other symptoms of a neuro- 
pathic character, it is a grave symptom, indicating organic disease of 
the encephalon, as effusion, meningitis, etc. A permanently downward 
direction of the axes of the eyes, with smallness of the face and great 
expansion of the cranium, is a sign of congenital hydrocephalus. The 
scalp in this disease is tense, bald, or sparingly covered with hair, the 
fontanelles and sutures open and enlarged, and the cranial bones yield 
to pressure. Great expansion of the cranium above the ears, while the 
frontal portion is not enlarged, or but slightly, denotes hypertrophy of 
the brain. 

The appearance of the general cutaneous surface possesses much 
greater diagnostic value in the diseases of infancy and childhood than 
in those of adult life. The eruptive fevers so common in the young, 
and comparatively rare in the adult, reveal themselves to us in great 
part by the changes which they cause in the appearance of the integu- 
ment. The peculiar color of the skin in constitutional syphilis, here- 
after to be described, and which is more marked in infancy and early 
childhood than at any other age, is a diagnostic sign of great value in 
obscure cases. In the infant the cold stage of intermittent fever is 
manifested, not by muscular tremors, but by lividity, pallor, and the 
goose-skin appearance of the surface. 

Bulbous enlargement of the fingers and incurvation of the nails are 
signs of cyanosis, and, therefore, of malformation at the centre of the 
circulatory apparatus, or of tuberculosis, or chronic pulmonary disease 
attended by malnutrition. Enlargement of the spongy portions of 
bones, causing prominences, softness, and bending of the bones, and 
consequent deformity of the limbs, patency of the fontanelles., a large 



ATTITUDE — MOVEMENTS — THE VOICE. 93 

and square shape of the head from calcareous deposit external to the 
cranium, and delayed dentition, are among the signs of rachitis. 

In early infancy the glands of the skin and mucous surfaces, or 
which connect by their orifices with these surfaces, are slightly de- 
veloped. Therefore, sensible perspiration and lachrymation are rare 
under the age of three months. A thick Meibomian secretion of a 
puriform appearance collecting between the eyelids is an unfavorable 
prognostic sign ; it indicates a state of great depression ; it is observed 
most frequently in cerebral and intestinal maladies shortly before death. 
Passive congestion of the vessels of the conjunctiva sometimes occurs 
under the same circumstances, due to feebleness of the heart's action, 
and imperfect capillary circulation. It indicates the near approach of 
death. 

Attitude — Movements — The Voice. 

A sharp, piercing cry, head firmly retracted, flexure of the limbs 
with a degree of rigidity, abduction of the great toe, clonic or tonic 
spasm of the muscles, irregular movements of one or more limbs, with 
consciousness impaired, or with mental hallucinations, are symptoms of 
grave disease of the cerebro-spinal system. Irregular muscular move- 
ments partly controlled by the will, and occurring during full conscious- 
ness, are symptoms of chorea, a disease nearly always ending favorably 
in children, though incurable in the adult. Contraction of the eye- 
brows, turning of the eyes and face from light, avoidance of noises, as 
if painful, are signs of headache. Frequent carrying of the hand to 
the ear, and pressing with the ear against the breast of the mother or 
nurse, are symptoms of otalgia. Frequent carrying of the fingers to 
the mouth in connection with fretfulness or other symptoms of suffering, 
indicates stomatitis, gingivitis whether from difficult dentition or other 
causes, painful pharyngitis, or some obstructive disease of the larynx. 
Frequent rubbing or pressing the nose may be due to intestinal worms 
or intestinal irritation fro;n other causes. It may be due to coryza or 
headache. Frequent forcible rubbing or striking the nose should lead 
to a careful examination and perhaps guarded prognosis. It often in- 
dicates grave cerebral disease, and may be a precursor of convulsions. 

In severe obstructive disease of the larynx the child is restless, 
moving from side to side. In most inflammations of the respiratory 
organs, a semi-erect position gives most relief. The voice in severe 
laryngitis is often hoarse or indistinct, and is usually so in the pseudo- 
membranous form ; in pleuritis or pneumonitis it is restrained and 
abrupt, since the movements of the walls of the chest give pain. 

The voice in severe diseases of the abdominal organs is feeble and 
plaintive. It is sometimes short and restrained in acute dyspepsia, in 
peritonitis, and in cases of great abdominal distention. The horizontal 
position gives most relief in abdominal diseases. In case of abdominal 
pain the patient often presses his hand upon the abdomen and flexes 
his thigh over it. Perfect quietude, with features sunken, and un- 
changed by smile or crying, is a symptom of severe and exhausting 
diarrhceal affections. 



94 DIAGNOSIS OF INFANTILE DISEASES, 



Respiratory System. 

The respiration of the infant under the age of six months is very- 
irregular, and it is more irregular the nearer the time to birth. If the 
new-born infant be closely observed, it will be seen to sigh often ; it 
breathes pretty uniformly and regularly for a moment, and then, with- 
out appreciable cause, the respiration is intermitted ; it holds its breath 
when it smiles or moves its head, or even its limbs; it is very subject 
to hiccup ; this is more common the first week of life than at any other 
age. So much is the breathing of the young infant disturbed by these 
causes, that the number of respirations ordinarily varies in consecutive 
minutes. In order, therefore, to determine with accuracy the frequency 
of the normal respiration for this time of life, it is necessary to take the 
average of several observations. 

At birth, while the function of the heart has for months been regu- 
larly performed, the lungs are still quiescent. The one organ has been 
active during the greater part of foetal development, the other is yet 
untried. Hereafter, in the new order of things, so intimate is the re- 
lation between the heart and lungs, that the proper performance of the 
function of the one is essential to that of the other. Therefore, the 
commencement of respiration and the return of circulation, which is 
modified and temporarily arrested at birth, are nearly simultaneous. 
Respiration begins in the first half-minute of independent existence ; 
often, indeed, attempts to inspire occur before delivery is completed. 
The exceptions to this early establishment of respiration are after 
tedious or unnatural births. The establishment of the new circulation 
is a moment later. 

Respiration in Health. — As the air-cells at birth are closed, the 
establishment of respiration is difficult. The air at first penetrates a 
few pulmonary cells, but gradually more and more are inflated through 
the forcible inspirations w T hich the crying of the infant produces, till 
after a variable time, respiration becomes easy and complete. If the 
cry be feeble, and especially if with this feebleness there be considerable 
congestion of the brain, the result of tedious birth, the full establishment 
of respiration is in a corresponding degree gradual and slow. 

The frequency of the respiration in health should be ascertained, in 
order to determine whether, in a given case, it be abnormally acceler- 
ated. The following table embodies the result of observations which I 
have made, in order to determine the normal frequency of respiration 
in the first year of life. 



RESPIRATORY SYSVTEM 



95 



Normal Infantile Respiration {number per minute). 








Age. 






From first 


From close 


From close 


Close of 


Close of 






half hour to 


of first week 


of first 


third to close 


sixth month 






close of first 


to close of 


month to 


of sixth 


to close of 




First 


week. 


first month. 


close of third 


month. 


first year. 




half 
hour. 






































© 


p, 


© 


ft 


© 


ft 


© 


ft 


©' 


ft 












© 




© 




o 




© 
































"m 


£ 


13 


£ 


03 


fS 


"3 


£ 


In 






< 


< 


< 


< 


< 


< 


< 


< 


< 


< 


Number of observations 


29 


2S 


14 


13 


13 


16 


10 


25 


7 


19 


6 


Extreme number of res-) 
pirations per minute j 

Mean number of respira- \ 
tions per minute J 


25-104 


32-64 


40-64 


40-96 


28-GO 


32-68 


28-52 


36-88 


24-40 


2S-64 


24-36 


48.5 


52 


52 


59 


45 


51 


39 


54 


33 


41 


29 



As the child advances from the age of one year, the number of respi- 
rations per minute gradually diminishes ; but through the whole period 
of childhood it remains greater than in the adult. At the age of five 
years, when the child is quiet, but awake, it is about 27 ; at the age of 
ten years, about 22. 

Respiration in Disease. — In cerebral diseases the respiration 
becomes slow, and if somnolence occur, intermittent, and accompanied 
by sighing. In young infants, in the drowsiness which supervenes 
when the blood is imperfectly decarbonized, during severe attacks of 
capillary bronchitis, or broncho-pneumonia, respiration is likely to be 
intermittent. 

In inflammatory diseases of the larynx and trachea, respiration is 
but slightly accelerated, and, if there be no obstruction, its rhythm is 
normal ; if there be obstructive disease, its rhythm is altered ; the inspi- 
ratory act is lengthened. In bronchitis, respiration is accelerated in 
proportion to the degree of extension downward of the inflammation. 
It is in no disease more accelerated than in severe capillary bronchitis. 

In pleuritis and pneumonitis, the respiration is accelerated in pro- 
portion to the extent and acuteness of the inflammation. Inspiration 
ending abruptly, and succeeded by an expiratory moan, is a symptom 
of both pleuritis and pneumonitis in their acute stages. In certain 
cases of irritative or inflammatory disease of the abdominal organs, 
respiration presents a similar character ; it is modified in this manner in 
consequence of the pain experienced in movements of the diaphragm. 
Ordinarily, however, in abdominal diseases, respiration is nearly natural. 

The cough is an important diagnostic symptom. It is loud and 
sonorous in spasmodic croup, hoarse or harsh in true croup, clear and 
distinct in bronchitis, suppressed and painful in the early stages of 
pneumonitis and pleuritis, convulsive and with more inspirations than 
expirations in pertussis. A cough due to coexisting bronchitis is one 
of the first and most constant symptoms of measles. Typhoid and 
remittent fevers, difficult dentition, intestinal worms, irritating ingesta, 
and severe burns, sometimes give rise to a cough, which is nearly dry 



96 DIAGNOSIS OF INFANTILE DISEASES. 

and painless. Occurring in such diseases, it is sometimes dependent on 
more or less bronchitis, to which the primary disease has given rise. 

A strongly marked nasal or palatal cry is present in syphilitic ozgena, 
hypcrtrophied tonsils, and paralysis of the soft palate. If these can be 
excluded, it indicates retropharyngeal abscess. On one occasion Pol- 
litzer heard this cry in a baby that the mother said was well ; but he 
introduced his finger in the fauces, felt the expected swelling, and, by 
an incision, evacuated a considerable amount of pus. 

An excessively prolonged, loud-toned expiration, with normal inspi- 
ration, and without dyspnoea, is, according to Pollitzer, an early symp- 
tom of chorea, sometimes preceding all other symptoms. He was once 
called to a child, apparently well and asleep, in whom this symptom had 
continued two hours, and was supposed by the mother to indicate croup. 
Later the ordinary symptoms of chorea appeared. The same author 
regards a high thoracic, continued sighing inspiration as almost pathog- 
nomonic of weak heart, and of certain cases of acute, fatty heart. Un- 
like the condition in laryngeal stenosis, while the diaphragm is nearly 
inactive, the accessory muscles of inspiration act strongly. This symp- 
tom occurs early, before the lividity or pallor, or weak pulse, or cold 
extremities. 

A distinct pause after each expiration, ascertained in a quiet room 
by placing the ear close to the mouth, distinguishes laryngeal catarrh 
from croup. (Pollitzer.) Stridulous inspiration usually indicates acute 
laryngeal catarrh, but I have, in a considerable number of instances, 
been asked to prescribe for infants with stridulous respiration, which 
commenced early, perhaps in the first or second month, and continued 
night and day till about the close of the first year, when, in the develop- 
ment of the child, it ceased. It is attended by no dyspnoea or suffering, 
does not interfere w T ith the nutrition or growth, is not benefited by any 
known treatment ; and it seems that it may exist within physiological 
limits. 

A shrill, loud cry, night after night, in sleep, while the child is well 
in the daytime, is probably due to dreams, and it may be treated by a 
large dose of quinine at bedtime, but a full dose of the bromide of 
potassium or sodium is, perhaps, more apt to give relief. A cry, 
lasting five or ten minutes, and occurring several times in the day, indi- 
cates spasm of the bladder, especially if dysuria be present. It is best 
treated by belladonna, provided that there be no calculus. A cry, during 
defecation, indicates fissure *of the anus, and is to be treated by an 
ointment of zinc and belladonna. A violent and protracted cry, with 
restlessness, pressing the head on the pillows or breast of the nurse, and 
frequent carrying of the finger to the ear, indicate otalgia. 



Circulatory System. 

In all ages and countries the pulse has been considered an important 
symptom, both in diagnosis and prognosis. It aids the practitioner in 
determining, approximately, not only the character but the gravity of 
diseases. It is somewhat remarkable, from the importance which is 



CIRCULATORY SYSTEM 



97 



attached to the pulse in medical practice, that its natural frequency and 
its character in infancy are not more accurately known. It is true that 
eminent observers, as Trousseau and Valleix, have published statistics 
relating to the infantile pulse in health, but these statistics disagree, and 
therefore do not afford a reliable standard with which to compare the 
pulse in disease. Moreover, some published statistics of the pulse pos- 
sess but little value, from the small number of observations ; some from 
the fact that records of the infantile pulse are grouped with those of 
older children ; and others because the state of the infant, as regards its 
activity or emotions, is not mentioned. 

Pulse in Health. — It is not easy to collect statistics of the pulse 
during the period of infancy, which are entirely free from error, since 
often slight derangements of the system in the infant frequently occur, 
which are not manifested by any marked symptoms, but which produce 
acceleration of pulse. In collecting the following statistics, sources of 
error, so far as possible, were avoided. 

The movements of the heart commonly begin about one-eighth of a 
minute after birth. They are at first slow, the ventricular contractions 
not numbering more than eight or ten by the close of the first quarter 
minute. In the second quarter the cries are vigorous, and the pulse 
now is rapidly accelerated, rising commonly above 120, and sometimes 
above 160 beats per minute. In fifty-seven observations of the pulse 
in healthy infants during the first half hour of life, after the first 
quarter of a minute, I found that the extremes, with one exception, were 
104 and 164— average, 139. 

Table of Infantile Pulse in Health. 





Age. 








From close of 


From close of 


From close of 


From close of 






first week to 


first month to 


third month to 


sixth month to 








close of first 


close of 


close of 


close of first 








month. 


third. 


sixth. 


year. 




Awake. 




Awake. 




Awake. 




Awake. 




Awake. 






Quiet ; 


p, 


Quiet ; 


Pi 


Quiet ; 


Pi 


Quiet ; 


& 


Quiet ; 


a 




moving 


o 


moving 


o 


moving 


o 


moving 


■a 

< 


moving 


® 




slightly ; 


< 


slightly ; 


< 


slightly ; 


< 


slightly ; 


slightly ; 


<5 




nursing 




nursing. 




nursing 




nursing 




nursing. 




No. of oh-") 
serrations j 


22 


16 


10 


10 


15 


17 


25 


6 


20 


3 


Extremes . 


104-152 


108-140 


124-160 


104-144 


112-148 


104-132 


112-146 


104-116 


112-144 




Mean 


12(3 


122 


139 


118 


132 


118 


129 


108 


127 


109 



" M. Ledeberder," says Bouchut, "could only count the pulse in the 
first minute of life in six children, and he has- observed from 72 to 94 
pulsations." Valleix estimates the pulse, between the ages of two and 
twenty-one days, at 87. Trousseau states that the pulse, in the first 
week of life, varies from 78 to 150 ; and Dr. Gorham's observations are 
in the main similar to Trousseau's. My observations, as seen from the 
above table, do not correspond with the assertions of Ledeberder and 
Valleix. Indeed, if there were no conflicting testimony, there would 

7 



98 



DIAGNOSIS OF INFANTILE DISEASES, 



still be a strong presumption that these authors are in error, for we 
would not suppose that the pulse of the infant, in whom there is greater 
functional activity, both muscular and visceral, would fall so much be- 
low that of the foetus. It is probable, from the expression, " could only 
count the pulse in six children," that Ledeberder, and per- 
haps Valleix, counted the pulse in the wrist, which, with exceptional 
cases, is very difficult and often impossible in the first week of life, and 
that they missed some of the beats, or, not unlikely, sometimes counted 
their own pulse. Immediately after birth there is so little force of the 
ventricular systole, and the extreme arteries, therefore, of the s} T stem 
pulsate so feebly, that neither in the limbs nor at the anterior fontanelle 
can the frequency of the pulse be readily ascertained. It can be readily 
and accurately ascertained only by auscultation, or by placing the hand 
on the precordial region, or directly after birth by the pulsations in the 
umbilical cord. 

The average pulse of the healthy infant in the first and second months 
is, according to Trousseau, 137 per minute, 128 from the third to the 
sixth month, and 120 from the sixth to the twelfth month. It is seen 
that his observations agree closely with mine, as regards infants who 
are quiet, but awake. One point of interest, established by the above 
statistics, is the great diminution in the frequency of the pulse in sleep. 

Pulse during or after Active Movements or Great Mental Excitement. 





Age. 






Close of first 


Close of first 


Close of third 


Close of sixth 




First week. 


week to close to 


to close of third 


to close of sixth 


month to close 






first month. 


month. 


mouth. 


of first year. 




140 


162 


176 


132 


132 




160 


156 


152 


148 


144 




140 


140 


158 


148 


152 




152 


152 


144 


144 


182 




... 




152 


156 


198 








180 


156 


160 


Extremes . 


140-160 


146-162 


144-180 


132-156 


132-198 


Mean 


148 


152 


160 


• 147 


156 



It is seen, by the above table, that by active exercise, or great mental 
excitement, the pulse may become as rapid as in grave diseases. There 
is greater acceleration of pulse from the emotions and from exercise in 
feeble than in robust children. Obviously, in order to determine to 
what extent the pulse is accelerated in disease, it is necessary that it 
should be counted during a state of quietude. As the age increases, it 
is less and less influenced by the emotions and physical exertion ; still, 
during the whole period of childhood, such influences do have more or 
less effect on its frequency. 

Pulse in Disease. — Febrile and inflammatory diseases produce 
greater acceleration of pulse in early life than in maturity. Diseases, 
or derangements of system, particularly those of the digestive organs, 



ANIMAL HEAT. 99 

which do not materially affect the pulse in the adult, often cause ac- 
celeration of it in children. The febrile pulse of early life usually has 
exacerbations in its frequency. These commonly occur in the latter 
part of the day. Distinct and more or less regular febrile exacerba- 
tions and remissions are common in several diseases of early life, some 
of which are serious, while others involve little danger. Among these 
diseases may be mentioned difficult dentition, intestinal worms, incipient 
meningitis, and constipation. An intermittent and irregular pulse is 
common in fully developed meningitis and certain other severe organic 
diseases of the encephalon. It may be due also to disease of the heart, 
and it also occurs in some children from temporary disturbance of the 
digestive function. The pulse is slow in compression of the brain, and 
in sclerema of the new-born. 



Animal Heat. 

The internal temperature of the body in health is uniform. In 33 
infants under the age of seven days, M. Roger found the average tem- 
perature 98.6° Fahr., while in 25, from four months to fourteen years 
old, it was 99°. The external temperature alone varies in health, 
according to the temperature of the atmosphere. 

Elevation of temperature above the normal standard is a sign of in- 
flammatory and febrile diseases. The increase of heat varies accord- 
ing to the nature of the disease and its type. In favorable cases of 
inflammation and in simple fevers it is not ordinarily more than two or 
three degrees. The greater the severity and malignancy of inflam- 
matory and febrile diseases, the greater the elevation. An elevation 
of more than six degrees indicates a malady which is likely to prove 
fatal. It is rare that the temperature, even in fatal cases, rises above 
107°. In measles, in the eruptive stage it is from 101° to 103° ; in 
scarlatina from 102° to 104°, if no complication exist. In diphtheria 
the temperature is elevated at first, but it frequently falls to nearly the 
normal during the stage of profound toxaemia. 

Reduction of the internal temperature is an unfavorable prognostic 
sign ; it is observed, a few hours before death, in infants who are 
greatly reduced by certain chronic diseases, as entero-colitis. In these 
cases the tongue and even sometimes the breath communicate to the 
finger or hand a sensation of coldness. 

The importance of thermometric observations, as an aid to the diag- 
nosis of children's diseases, is within a few years more fully recognized 
by the profession. Two diseases which, in their commencement, present 
very similar symptoms, often vary as regards the temperature. Thus, 
meningitis, presenting in its first stages symptoms very similar to those 
of typhoid fever, has a lower temperature till an advanced stage, 
when the amount of heat increases. 



100 DIAGNOSIS OF INFANTILE DISEASES. 



Digestive System. 

Inspection of the buccal and faucial surfaces discloses some of the most 
frequent local diseases of infancy, as the various forms of stomatitis, and 
others which, though not frequent, involve great danger, as gangrene of 
the mouth, diphtheria, and retro-pharyngeal abscess. Inspection of the 
tongue aids in determining in many cases whether the disease be pur- 
suing a favorable course, or has become asthenic, and is exhausting the 
vital powers. 

Febrile movements, even when slight, give rise to coating of the 
tongue, and intumescence and distinctness of its follicles. The eruptive 
fevers are attended by changes upon the buccal and faucial surfaces 
which possess diagnostic and prognostic value. Hyperemia of these 
surfaces appears early in rubeola and scarlatina, prior to those phe- 
nomena which are justly regarded as pathognomonic. It is, therefore, 
often an important sign in the initial period of these diseases when the 
diagnosis is obscure. The appearance of the fauces in diphtheria and 
croup, indicating not only the nature of the disease, but its gravity, 
need only be referred to in this connection. 

Inspection of the buccal and faucial surfaces sometimes enables us to 
form a probable opinion in reference to the nature of diseases which 
are seated in other parts. In the infant protracted stomatitis is a 
common accompaniment of chronic diarrhoea, and it indicates its in- 
flammatory nature. 

Vomiting is more frequent in infancy than in childhood, and in either 
period than in adult life. It is common in cerebral affections, and is 
one of the first symptoms of scarlet fever, and is not uncommon though 
less frequent, in the commencement of the other essential fevers and of 
acute inflammations. It is a symptom of indigestion, entero-colitis, 
cholera infantum, and intussusception ; it is common, also, after the 
paroxysmal cough of pertussis, and not infrequent in the bronchial in- 
flammations of young infants. In both these diseases it is excited by 
the muco-purulent matter upon the faucial surface. 

Intestinal gas is in part secreted or exhaled from the mucous mem- 
brane, as the experiments of Hunter and others have shown, and is in 
part the product of chemical changes in the food.' A certain amount 
of gas in the intestines, is normal; it subserves a useful purpose. An 
abnormal amount of it is common in various diseases, as indigestion, 
chronic entero-colitis, peritonitis, typhoid fever. It is a frequent cause 
of gastralgia and enteralgia in the infant. In scrofulous or feeble 
infants, with impaired muscular tonicity and faulty digestion, the abdo- 
men is often habitually more or less distended with gas, which does not, 
under such circumstances, give rise to pain or other local symptoms ; it 
has significance as showing the general condition of the child. 

In the rachitic, whose thorax is compressed and liver often enlarged, 
while the vertebral column is shortened, the abdomen is commonly pro- 
tuberant. In feeble children, not decidedly rachitic, whose lungs are 
seldom fully inflated, and whose chests are consequently depressed, the 
abdomen is also prominent. The accompanying woodcut represents 



DIGESTIVE SYSTEM. 



101 



Fig. 5. 



one of these cases, presented for treatment at the outdoor department 
at Bellevue. 

In feeble children who have suffered from repeated and protracted 
attacks of bronchitis, and whose chest walls are consequently depressed, 
a similar abdominal prominence occurs. 

Retraction of the abdominal walls is common in meningitis, and in 
many exhausting diseases. Tenesmus is a 
symptom of intussusception in the infant, 
and of colitis in children. 

Much light is thrown on the character 
of intestinal diseases by the appearance of 
the stools. Muco-sanguineous stools accom- 
panied by fever, are a sign of colitis. Stools 
containing unmixed blood, and not accom- 
panied by fever, may result from a rectal 
polypus, and from purpura hemorrhagica. 
Scanty evacuations of blood, with obsti- 
nate constipation, are a symptom of intus- 
susception in infants. 

The alvine discharges of infants often 
present a green color; sometimes they have 
the normal yellow hue when passed from 
the bowels, but become green on exposure 
to the air, or from reaction of the urine. 
By the microscope the green coloring matter 
is seen to occur in small, irregular masses. 
This green substance has been supposed to 
be bile. I am convinced that, as it occurs 
in the stools of the infant, it is commonly produced by the action of 
the intestinal secretions on the contents of the intestines ; for I have 
often noticed that the contents in and above the jejunum were yellow, 
while in and below the ileum their color was green. Probably the 
green color is due to the formation of biliverdin from the bile which is 
mixed with the fecal matter. 

The green hue may occur from very different causes. It may be due 
to over-feeding, to the action of cold, to irritating ingesta, to inflamma- 
tion, etc. ; it may be transient, subsiding within a day or two, or it may 
continue several days. All infants, at times, have green evacuations, 
even when they appear in good health. 

In the commencement of a large proportion of diarrhoeal maladies 
in infancy the stools give an acid reaction with litmus-paper. This 
acid, if in considerable quantity, is irritating, increasing the peristaltic 
movements of the intestines, and the functional activity of the intestinal 
follicles, causing erythema of the skin around the anus, and reacting 
upon and intensifying the intestinal disease. Hence the indication for 
the use of antacids in' the diarrhoeal affections of infancy. 

The presence of intestinal worms and the species may be ascertained 
by microscopic examination of the stools of the child who is affected 
with these entozoa. The stools contain ova, which differ in size and 
shape according to the species of worm. 




102 DIAGNOSIS OF INFANTILE DISEASES. 



Nervous System. 

Pain. — This symptom affords important aid to the physician 'in deter- 
mining the seat and nature of the diseases of children. Pain in the 
head may occur in them from coryza involving the frontal sinuses, or 
from febrile movement in the commencement of an essential fever, or 
of inflammation of one of the organs of the trunk. Produced by such 
a cause, it abates in two or three days. If it be protracted, whether 
constant or intermittent, it is in many cases not neuralgic, as it so 
often is in the adult, but is clue to organic disease of the brain or 
meninges. Complaint, therefore, of headache in a child, without any 
apparent general cause or local cause external to the cranium, should 
awaken solicitude, and, if it be protracted, the physician should ex- 
amine carefully in reference to the presence of a cerebral or meningeal 
disease. Mild frontal headache, continuing for weeks or months, is 
neuralgic and due to anaemia. It is increased by pressure over the 
occiput and upper cervical vertebrae. 

Grave thoracic or abdominal inflammations in the adult are almost 
always attended by a corresponding amount of pain and tenderness ; 
but in children these symptoms are often absent, or, when present, are 
frequently not commensurate with the amount of disease. Thus, entero- 
colitis of nursing infants is, in a large proportion of instances, almost 
free from these symptoms. 

Pain in the chest or abdomen, occasional or constant, continuing for 
weeks or months, with fever, and unattended by thoracic or abdominal 
disease, indicates caries of the vertebrae. Its most common seat is the 
epigastric, umbilical, or hypochondriac region. It is a neuralgia clue to 
irritation of the sensitive root of one or more of the spinal nerves. It is 
a very important symptom to the diagnostician, showing the nature of 
the disease, which in its incipiency is so obscure. Pain in the leg, 
especially the inside of the knee, is of a similar character, indicating 
disease of the hip-joint. 

Children with certain acute febrile and inflammatory diseases some- 
times have hyperaesthesia of portions of the surface ; it is especially 
marked upon the anterior aspect of the trunk. The physician might 
be misled into the belief that the tenderness occurred over the seat of 
the disease and indicated an inflammation ; but the pain of hyperaes- 
thesia can be diagnosticated from that of inflammation by the fact that 
it is so extensive, is less on firm than light pressure, and is especially 
observed upon the inner surface of the thighs. The symptoms per- 
taining to the nervous system occurring in the various diseases treated 
of in this book will be fully described in connection with those diseases, 
and, therefore, need not detain us in this connection. 



THERAPEUTICS. 103 



CHAPTEE XV. 

THERAPEUTICS. 

The young practitioner is often perplexed in deciding exactly what 
dose of the stronger and more dangerous medicinal agents to prescribe 
for a child. A practical rule, which holds good for many medicines, 
has been proposed by Dr. Cowling, as follows : " The proportional dose 
for any age under adult life is represented by the number of the follow- 
ing birthday divided by twenty-four." This rule is inadmissible for 
infants under the age of six months, but will apply for those that are 
older, for the use of a large number of medicines. Another rule pro- 
posed by another British physician, Professor Clarke, is based on differ- 
ences in weight of children and adults: The adult 'dose is represented 
by 150. The dose of a child is determined by dividing its weight in 
pounds by 150. But it is an interesting fact, and one of practical im- 
portance, that children bear and often require, in order to obtain the 
desired effect, a much larger proportionate dose of certain agents than 
adults. This is partly attributable to the active elimination in child- 
hood. Belladonna is notably one of the agents which children tolerate ; 
and it may be added that some children can take a much larger dose 
of it than others, without producing the physiological effects. Thus, 
recently, I increased gradually the tincture of belladonna to twelve 
drops for a child of four years, without producing the usual efflo- 
rescence; and Farquharson says " the dose . . . I have pushed in 
a child of ten, suffering from incontinence of urine, to f,5ij (British 
Pharmacop.) with good effect, and the development of mild forms of 
physiological disturbance." Arsenic is also better tolerated by children 
than adults. An infant of six months can take two-drop doses of Fow- 
ler's solution three times daily without ill-effect. Prussic acid, strychnia, 
iron, ipecacuanha, and alcohol, are also required in larger proportionate 
doses in childhood than is indicated by the rule either of Dr. Cowling 
or Professor Clarke. 

When practicable, medicines should be given in the liquid form. Those 
not soluble may often be given in suspension, in some vehicle which in 
great part disguises the taste. A good vehicle for the bitter vegetables, 
as the salts of quinia, is the elixir adjuvans of Caswell and Hazard. 
The following is the formula for its preparation 

]£. — Cort. aurant. ...... 

Pulv. semin. coriandr. 

Pulv. semin. carui 

Pulv. cort. pruni Virginianae 

Pulv. rad. glycyrrhizae .... 

Menstruum, Alcohol 

Aquae ...... 

Percolat. O. v, et adde — 

Syr. simplic. ...... 

Aquae aa. Oijss. 



5*3- 

| IV. 

S|vj. — Misce. 

partis j. 

part. ijss. — Misce. 



104 THERAPEUTICS. 

The elixir adjuvans may also be advantageously employed in the ad- 
ministration of many other medicines apart from those -which are repul- 
sive on account of their bitterness. It holds them in suspension so that 
if they have a greater specific gravity than the elixir it is necessary to 
shake the bottle thoroughly before using it. The elixir taraxaci comp. 
is another good vehicle for bitter vegetables, although, like the elixir 
adjuvans, not officinal. I am sure from many observations, that un- 
pleasant doses are apt to be wasted to a greater or less extent, and the 
repugnance of children to medicines employed has induced many a 
parent to seek other and less disagreeable modes of treatment. Chem- 
istry has greatly aided the therapeutics of childhood, in that it has 
enabled us, in so many instances, to prescribe the active principles in 
place of the large, nauseous doses formerly employed. 



PART II. 

CONSTITUTIONAL DISEASES. 



SECTION I. 

DIATHETIC DISEASES. 



CHAPTEK I. 

EACHITIS. 

Rachitis, or rickets, is regarded as a constitutional disease, though 
the symptoms and lesions which characterize it pertain chiefly to one 
of the systems. It occurs in the first years of life, and, therefore, 
during the period of most active growth of the skeleton. It is mani- 
fested by an abnormal nutrition and changed physiological action of the 
bone-producing tissues, namely, the epiphyseal cartilage and the peri- 
osteum, and by the arrest, more or less complete, of the deposition of 
lime-salts in these tissues. 



Frequency of Rachitis. 

Rachitis is a common result of faulty diet and of antihygienic con- 
ditions, and is, therefore, frequent among the poor of cities, and 
especially in families who dwell in crowded tenement houses. It has, 
heretofore, been prevalent in the city infantile asylums, but of late 
years, as regards at least the city of New York, it is much less common, 
in consequence of the greater attention now given to sanitary require- 
ments in the management of these institutions. Mild cases of rickets 
are often overlooked, since physicians may not be summoned to attend 
them, while even if they be summoned, many, who have not given 
particular attention to this disease, are apt to err in diagnosis, and to 
refer the symptoms to some other than the true cause. Commencing 
gradually and insidiously, rachitis not infrequently continues for months, 
even in its typical form, before a correct diagnosis is made. In the 
absence of deformity, which is a late symptom, the fretfulness, tender- 
ness of surface, and perspirations, receive a wrong explanation. Prac- 

(105) 



106 RACHITIS. 

titioners who have heretofore given little attention to this malady, and 
who believe it to be rare, if they are instructed in reference to its 
characteristic signs, and look for them in their visits among the city 
poor, are surprised at the number of cases with which they meet. A 
few years since, in the New York Infant Asylum, my attention was 
directed to a rachitic child, whose head had so changed from the normal 
shape, that the nurses, as well as the physician, had remarked the dif- 
ference. Prompted by the occurrence of this case, which had gradually 
developed under my eyes, I made a careful examination of all the 
infants, and discovered, what I had not previously suspected, that about 
one in nine had become rachitic. In most of the infants the disease 
was mild, but with symptoms so characteristic that it was readily recog- 
nized. By effecting certain improvements in the diet, among which 
was the daily allowance of beef-tea to the older infants, rachitis, unless 
of a mild type, has since been rare in this institution. 

The late Dr. John S. Parry, of Philadelphia, stated that at least 
twenty-eight per cent, of all the children, between the ages of one 
month and five years, who came under his observation in the Philadel- 
phia Hospital during the three years preceding the publication of his 
paper, in 1872, were rachitic. This is certainly a larger proportion 
of those who present indubitably rachitic symptoms than occurs in any 
of the three New York institutions for children with which I have an 
official connection. In the New Y r ork Foundling Asylum, with its six- 
teen hundred inmates, and in the Bureau for the Relief of the Out-door 
Poor, where over eight thousand children are annually treated, rachitis 
is certainly less frequent than is indicated by the statistics of Dr. Parry. 
In Europe, from the testimony of many observers, both continental and 
British, rickets is very common among the families who seek medical 
advice in the institutions of charity. Bitter von Rittershain finds that 
thirty-one per cent, of all the children who are brought to the Prague 
Medical " Poliklinik," are rachitic, and Prof. Henoch states that the 
proportion is equally large in the families of Berlin, who are in similar 
reduced circumstances. According to Dr.. Gee, whose statement was, 
however, made as far back as 1867-68, of the patients under the age 
of two years, in the London Hospital for Sick Children, 30.3 per cent, 
are rachitic. Both Dr. Hillier and Sir Wm. Jenner not only allude to 
the frequency of rachitis, but state that it is the cause of many deaths 
in London families. It appears, therefore, that this malady, though 
not rare in American cities where ill-fed and ill-housed families con- 
gregate, is less prevalent than in families similarly situated in Europe. 
The greater immunity in this country must be due to other causes besides 
difference in nationality, for the poor of American cities are largely of 
foreign birth. 

But rachitis does not occur exclusively among the poor. Children 
of well-to-do families are also liable to it, provided that the conditions 
soon to be enumerated are present. Ignorance or disregard of the 
hygienic requirements of young children, and especially the use of 
improper diet, leads to the development of rachitis in wealthy as well 
as in destitute families. Merei, in his treatise on the Disorders of 
Infantile Development (London, 1855), states that in Manchester, 



AGE AT WHICH KACHITIS OCCURS. 



107 



where his observations were made, one child in every five, in families 
in comfortable circumstances, presented rachitic symptoms ; and he be- 
lieves that this cannot be much above the real proportion in " the whole 
of the wealthy classes." 

Rachitis, in its milder form, is not uncommon in affluent families in 
this country, the cause of the delayed dentition, the fretfulness, and per- 
spiration, not being suspected in many instances, as I have had oppor- 
tunities to observe. Often family physicians are not consulted in 
reference to such symptoms, and when they are called in, so little 
attention has rachitis received on the part of many practitioners, that 
they are very apt to overlook the true pathological state which is present. 
Still, admitting the fact that many cases are not diagnosticated, I repeat 
that, though rachitis is not uncommon on this side of the Atlantic, its 
percentage of frequency falls below that observed in European cities, a 
fact which may be due to less crowding in their domiciles, and to a 
more liberal and better supply of food among the families of the poor 
in this country. 



Age at -which Rachitis Occurs. 

Rachitis is, with few exceptions, a disease of infancy, commencing 
prior to the age of two and a half years. Now and then, it, or a state 
closely resembling it, occurs in the fortus, causing 
deformities, such as are present in typical cases. 
In the Kinderspital Museum, at Prague, is a spec- 
imen showing this, and described by Ritter. Hink 
and Winkler also describe such cases, and Virchow 
alludes to a specimen in the Wurzburg Museum, 
which exhibits such deformities as characterize 
rachitis. Bednar even regards foetal rachitis as not 
uncommon (Hillier, Parry). In the Wood Museum 
of Belle vue Hospital, is a skeleton which is prob- 
ably similar to those in the Prague and Wurzburg 
Museums. It shows in a striking manner the 
deformities of this congenital disease. The case 
occurred in my practice, and the dissection was 
made by Prof. Francis Delafield. The infant, born 
at term, died a few hours after birth from atelectasis, 
apparently produced by the contracted state of the 
thoracic walls. The parents were hard-working 
English people, whose mode of life and surroundings 
were such as are known to conduce to rachitis. 
They were free from syphilitic taint. The accom- 
panying woodcut (Fig. 6) represents this skeleton. 

The following remarkable case of supposed foetal hours after birth - 
rachitis was related to me by Heitzmann," w T hose interesting experi- 
ments will be presently detailed: 

Case 1. — A woman who had frequently inhaled the vapor of lactic 
acid each day, for many months, as she was employed to feed animals 




Skeleton of a rachitic 
infant which died a few 



108 KACHITIS. 

with this agent, gave birth to an infant, at term, which died immediately 
after it was born. It exhibited the signs of congenital rachitis in a high 
degree. The skull bones were completely absent ; in the cartilages of the 
bones of the extremities, and in those of the ribs, there were scanty 
depositions of lime-salts, and numerous infractions. The death of the 
child was evidently due to the absence of the skull bones, inasmuch as 
the pressure of the womb during delivery had caused cerebral hemor- 
rhage. All the organs of the chest and abdomen were found in full 
development and healthy. 

We will see, hereafter, that the theory which attributes rachitis, in 
certain instances, to a chemical irritant, is substantiated by experiment, 
and that it has already been shown that two such agents, phosphorus and 
lactic acid, may cause this disease. Now, as the irritating action of 
phosphorus on the osseous system occurs when it is inhaled in the form 
of vapor, as well as when received in the ingesta, so lactic acid, if the 
above case be rightly interpreted, produces its special effect upon the 
bone-producing tissues when inhaled, as decidedly as when received in 
the ingesta or generated in the system. These remarks seem necessary 
for an understanding of this unusual case, although they anticipate what 
will be said under the head of etiology. In the New York Journal of 
Obstetrics for November, 1870, Prof. Abraham Jacobi also published 
the description of a case of congenital rachitic craniotabes. Whether 
or not we accept as genuine all the reported cases of foetal rachitis, 
there can be little doubt, from the number of observations already made 
and carefully recorded, and from the opinion of high authorities like 
Virchow, that such cases do occur. 

Enlargement of the costo-chondral articulations known as the " ra- 
chitic rosary," which is one of the earliest and most reliable signs of 
rickets, has been observed, though rarely, in infants only a few weeks 
old. Dr. Parry saw it as early as the sixth week after birth, 1 and Dr. 
Gee at the third or fourth week. 2 This should not, however, be regarded 
as a sign of rachitis, unless the enlargement be so great that it can be 
readily appreciated by examination through the integument, or by sight, 
for in young children, with the bones in the process of normal develop- 
ment, «these joints usually have a diameter a little larger than that of 
the ribs. Rachitis, with few exceptions, begins within the first eighteen 
months of life. Though first detected and diagnosticated at a later 
date, it will ordinarily be ascertained, on inquiry, that its symptoms 
had an earlier beginning. Still, according to certain observers, it may 
have a considerably later commencement. Glisson, Portal, and Tripier 
state that they have seen it commence in children who were w^ell on 
toward the age of puberty. Sir Wm. Jenner states that he has seen 
children of seven and eight years, who were only beginning to suffer 
from rachitis. 3 

The following are the aggregate statistics of Bruennische, von Rit- 
tershain, and Ritsche, relating to the age at which rachitis occurs : 

1 American Journal of the Medical Sciences, January. 1872. 

2 St. Bartholomew's Hospital Reports, vol. iv. 

3 Lancet, December 11, 1880. 



CAUSES. 

• 




] 




No. of Cases 


uring the first half year, ...... 


. 99 


" " second half of first year, .... 




259 


" " " year, ....... 




342 


" " third year, ...... 




134 


" " fourth year, 




31 


" " fifth year, 




17 


etween the fifth and ninth years, .... 




21 


Aggregate, .... 




903 



109 



Causes of Rachitis. 

Inheritance. — In some infants there is an undoubted hereditary 
predisposition to rachitis. Feeble digestion and defective assimilation 
in the infant, which are, as we shall see, important factors in producing 
the rachitic state, are often traceable to disease or cachexia of one or 
both parents. The offspring of a tubercular, syphilitic, or otherwise 
enfeebled parent, is more likely to become rachitic than those of healthy 
and robust ancestry ; and it appears that disease of the mother is more 
apt to entail a rachitic predisposition than that of the father. Among 
the parental causes may be mentioned poverty, hardships, and defective 
nutrition of either parent ; age of the father, and exhausting discharges 
of the mother, such as purulent, hemorrhoidal, or uterine fluxes. 

Food, — Of the exciting causes, the most common is the use of food 
not sufficiently nutritive, or, if nutritious, not suited to the age and 
digestive powers of the child. Thin and poor breast-milk, and artifi- 
cial food of poor quality, or not suitable for the stage of growth and 
development, are common causes of rickets. Those children who "have 
been prematurely weaned, and who have been given a food which is not 
a proper substitute for the natural aliment, and those too long wet- 
nursed and not allowed the additional nutriment which they require, are 
especially liable to this disease. Those whose digestive power is feeble, 
from whatever cause, are more apt to become rachitic than those who, 
in a state of robust health, have a hearty digestion. Hence we meet 
with rickets as a sequel of various protracted and exhausting maladies 
during infancy. 

It might be supposed, from the nature of rachitis, that the use of 
food deficient in phosphoric acid and lime is the common cause of 
rachitis ; but facts show that this is not the correct view of its etiology, 
as it commonly occurs, although in its treatment these agents are of 
undoubted value. The disturbed and altered nutrition of the osteo- 
plastic tissues, namely of the epiphyseal cartilage and the periosteum, 
is the important factor in producing the rachitic bone disease, and this 
may occur although the ingesta contain a sufficient amount of phos- 
phoric acid and lime. Deficiency of these substances probably tends to 
diminish the amount of lime deposition, but it is not the essential 
element in the causation of the malady. This is to be found in the 
unhealthy condition and action of the cartilage and periosteum, or 
rather in the agencies, now partly ascertained, which produce the 
abnormal state and altered nutrition of these tissues. 



110 RACHITIS 



Artificial Production of Rachitis. 

The important fact has been ascertained by experiments on young 
animals, that rachitis can be produced, as I have already stated, by at 
least two chemical agents, which may be admitted into the system in 
the ingesta, and which exert an especially irritating action on the osteo- 
plastic tissues. Senator states, in Ziemssen's Encyclopedia, that 
" Wegner . . . has recently brought experimental evidence to 
show that true rickets may be artificially produced by the continued 
administration of very minute closes of phosphorus . . . together 
with a simultaneous withdrawal of lime from the food." The fact 
being established that it is possible to produce rickets by certain dele- 
terious principles in the ingesta, opens an interesting field for experi- 
mental inquiry. Since improper feeding and indigestion are known to 
sustain a causative relation to rachitis, experiments have been made to 
ascertain whether some chemical agent, developed in the system during 
the digestive process, or introduced with the food, may not cause rachitis 
as it ordinarily occurs in the infant. Among the foremost in that line 
of experiment has been Dr. Heitzmann, a resident of Vienna when his 
observations were made, but now a citizen of New York. 

In young children, acids, especially the lactic, are commonly produced, 
and often in large quantities, as the result of improper feeding, of indi- 
gestion, and of intestinal catarrh. The acidity of the infant's stools, 
under such conditions of ill-health, is well known. What more natural, 
then, than the supposition or belief that this acid, thus generated, 
sustains the same causative relation to rickets, as phosphorus in the 
experiments which have been made with that agent. But the acid 
which is produced so abundantly in disturbed states of the digestive 
apparatus in the infant, believed to be chiefly the lactic, must, in order 
to reach the bones and influence their nutrition, pass through the blood, 
which is always alkaline. This difficulty in the way of the theory that 
lactic acid is the irritating agent, is removed by physiologists, who tell 
us that among the organic acids the existence of lactic acid in healthy 
blood is not entirely beyond doubt, but that it has been found in the 
latter under abnormal conditions. 1 Lactic acid has also been found, 
after having made the circuit of the system, in the excretion from the 
kidneys. 

Heitzmann, in order to ascertain whether this acid sustained a causa- 
tive relation to rickets, made a series of experiments, which have passed 
into the literature of this disease, and he has kindly furnished me with 
their details, as follows : 

"March and, Ragsky, Lehman, Simon, and others have found free 
lactic acid in the urine of persons suffering from rickets and osteo- 
malacia. C. Schmidt discovered lactic acid in the liquid of malacic 
shaft-bones which were transformed into globular cysts. Encouraged 
by these chemical researches, I undertook a series of experiments on 
the action of lactic acid, administered both by the mouth and by sub- 

1 Heinrieh Frey, of Zurich. 



ARTIFICIAL PRODUCTION. Ill 

cutaneous injection, upon the bones of living animals, which experi- 
ments were begun in April, 1872, and continued until the end of 
October, 1873. The experiments were made upon five dogs, seven cats,, 
two rabbits, and one squirrel. On dogs and cats under one year of age, 
the lactic acid, given either by mouth or injection, in combination with 
restricted administration of calcareous food, produced swelling of the 
epiphyses of the shaft-bones and of the anterior ends of the ribs, at 
their attachments to the costal cartilages. This result was plain in the 
second week after the beginning of the lactic acid treatment. Up to 
the fourth and fifth weeks, the swelling of the epiphyses and of the 
ends of the ribs kept increasing, and then was accompanied by curva- 
tures of the bones of the extremities. As accompanying symptoms, I 
noticed catarrhal inflammation of the conjunctiva, of the mucosa of the 
bronchi, the stomach, and the intestines, with emaciation and convulsive 
movements of the extremities. The microscopic examination of the 
epiphyses gave an image fully identical with that of the epiphyses of 
rickety children. Upon continuing the administration of the lactic 
acid, the swelling of the epiphyses of the shaft-bones gradually increased, 
and so did the curvatures of the same bones. After four or five 
months of lactic acid treatment, under often repeated catarrhal inflam- 
mations of the above-named mucous layers, the shaft-bones became soft 
to such a degree that they could be bent like the branches of a willow- 
tree. After from four to eleven months of the same treatment, the 
microscopic examination of the bones gave a result corresponding with 
that obtained from the bones of women who have died with osteomalacia. 

" On the three herbivorous animals no swelling of the epiphyses was 
noticeable. One rabbit died three months and the other five months 
after the commencement of administration of the lactic acid, but with 
symptoms of inanition. No marked evidences of rachitis or malacia 
were traceable in the bones of these animals. The squirrel, on the 
contrary, which died after thirteen months of treatment with lactic 
acid, gave all the features of osteomalacia. 

"My experiments give the result that by continuous administration 
of lactic acid, at first rickets, and aftenuards osteomalacia, can be 
artificially produced in flesh-eaters ; ivhile in herbivorous animals, 
osteomalacia sets in without preceding symptoms of rickets. Through 
these experiments I have proved the identity in nature of these two 
diseases, the differences in their course being due to the difference in 
the age at which the solution of the lime-salts is established. 
Rickets can be produced on dogs and cats only under the age of ten or 
twelve months. Mr. Hess fed with lactic acid a door of the age of one 
and a half years, and failed to produce rickets. This result is in full 
agreement with my experiments. I maintain that lactic acid, though 
not free in the blood, if in contact with the tissues producing bone, or 
with fully developed bone, owing to its great affinity for lime, either 
prevents the formation of bone (rickets), or dissolves ready-made bone 
(osteomalacia)." 

On the other hand, rachitis sometimes occurs in infants who present 
no history of indigestion or of intestinal catarrh, and in whom there is 
no ground for the belief that lactic or any other acid is produced in 



112 RACHITIS. 

undue or injurious quantity. In a considerable proportion of such cases, 
inquiry elicits the fact of antihygienic conditions, but there is no evi- 
dence of imperfect digestion, or of gastro-intestinal catarrh, such as 
produces lactic acid. In the cases occurring in the New York Infant 
Asylum, alluded to above, some of the children had manifest gastro- 
intestinal derangement; but others, who were wet-nursed, gave no evi- 
dence of faulty digestion, though the nutriment which they received was 
probably insufficient ; for, as already stated, by providing a more liberal 
diet, by allowing among other articles the juice of meat, rachitis became 
much less frequent, and is seldom observed at present among the infants 
of that institution, unless in a ve'ry mild form. 

Virchow and others have suggested that the prime factor in causing 
rachitis is the use of a diet that is deficient in calcareous salts, and we 
have seen that in the interesting experiments of Dr. Heitzmann, the 
administration of calcareous food to the animals was restricted. Still, 
as Niemeyer has well said, deprivation or restricted use of the chalky 
salts cannot possibly cause the most important histological change in 
rachitis, namely, the proliferation of the epiphyseal cartilages and 
periosteum, and we must look for some other factor in the causation. 

Pathology furnishes many examples of chronic disease attended by 
proliferation of tissue, the causes of which are not uniform. Cirrhosis, 
with its proliferation of hepatic connective tissue, which, as we shall 
see, presents a similitude in some respects to rachitis, is sometimes 
undoubtedly produced by the irritating action of a chemical agent, to 
wit, alcohol ; but all physicians know that there are many cirrhotic 
patients who refrain entirely from the use of alcohol in any form. In 
like manner, it seems to me that, if we admit, as Ave must in the light 
of experiments, that certain chemical agents, notably phosphorus and 
lactic acid, introduced into the system or produced in it, cause rachitis 
by their irritating action, there are other typical cases in which there is 
no reason to suspect the operation of such agents. We must, therefore, 
remain in the belief that rachitis, like many other pathological pro- 
cesses, does not result from a fixed and uniform cause, but from con- 
ditions which vary to a certain extent in different patients. 



Anatomical Characters of Rachitis. 

For convenience of description, the course of rachitis is divided into 
three periods : (1) That of proliferation and altered nutrition of car- 
tilage and periosteum ; (2) That of curvature and deformity ; (3) That 
of reconstruction. 

Anatomical Characters in the Stage op Proliferation and 
Altered Nutrition. — Ossification of a long bone occurs from the 
epiphyseal cartilages, and from the periosteal or fibrous membrane 
which surrounds, nourishes, and protects the bone. Growth in length 
is from the former, in thickness from the latter. As regards the flat 
bone, while growth in thickness occurs from the periosteum, that in 
breadth is from the cartilage of its border, Avhich corresponds with the 
epiphyseal cartilage of the long bone. 



ANATOMICAL CHARACTERS. 113 

Cartilaginous Changes. — If we examine the epiphyseal cartilage of 
a long bone during normal ossification, we observe, first beginning at 
the distal end, a white zone, consisting of a hyaline matrix, in which 
are the usual cartilage cells. This constitutes most of the cartilage. 
Underneath this, and nearer the bone, is the zone of proliferation, the 
cartilage in which is softer and more yielding than that of the distal 
zone, in consequence of cell formation, and absorption of the matrix to 
make way for cell-groups. Each cartilage cell in the proliferating zone 
has divided into two cells, and each of these cells into two other cells, 
and the division has been repeated so that eight cells instead of one 
are observed, surrounded by a common capsule. The capsule becomes 
distended by the cell multiplication, and by the swelling of each cell, 
the size of which is considerably greater than that of the parent cell. 
Near the bone, namely, along the extremity of the diaphysis, the cell- 
groups, enclosed in their capsules, nearly touch each other, the matrix 
having, for the most part, been absorbed. The end of the diaphysis is 
covered with a layer of these cell-groups, about to undergo ossification, 
with almost no intervening matrix. The proliferating zone has very 
little depth. It appears to the naked eye as a very thin, scarcely per- 
ceptible layer of a reddish-gray color upon the end of the shaft. It is 
so shallow that it does not perceptibly increase the thickness of the 
cartilage. 

In rachitis, the state of affairs is different. The zone of proliferation, 
instead of being confined to a single, or at most a double, layer of cell- 
groups, consists of many layers involving nearly the whole epiphyseal 
cartilage. The cells, still enclosed in their distended capsules, undergo 
a more frequent division than in health, so that instead of groups of 
eight cells, as in the normal state, each group consists of from thirty to 
forty cells. Therefore, in rachitis, the proliferating cartilaginous zone 
is a broad cushion, very soft, of a grayish translucent appearance, causing 
the characteristic swelling observed around the joint. Over the distal 
end of the proliferating cartilage, there may still be a layer or zone, 
though perhaps of little depth, of normal cartilage, like that in health. 

Osseous Changes. — While this occurs, the ossifying process is also 
arrested. We indeed perceive an effort in the direction of bone forma- 
tion. The Haversian canals, surrounded by capillary loops, extend 
from the bone into the proliferating zone of cartilage. Their extension 
is effected by absorption of the matrix and appropriation of cell-groups 
which lie in their way. The cells in these groups, as they enter the 
Haversian system, become much smaller by a rapid segmentation, 
forming medullary cells. We also find, as further evidence of the 
attempt at bone-formation, granules and masses of lime scattered 
through the cartilage, and here and there spicule and nodules of true 
bone, springing up from the bony substratum of the shaft. Some of 
the canals extend far into the cartilage, nearly indeed to its free surface, 
but most of them terminate in its lowest portion. The growth of bone 
in thickness occurs from the under surface of the periosteum. In 
health, a soft, vascular, germinal tissue springs from the periosteal 
surface, and rapidly receives lime-salts, and is transformed into bone. 
This germinal tissue, consisting largely of capillaries arising from the 

8 



m 



R A C II 1 T 1 S 



fibrous tissue of the periosteum, is a very thin substratum, barely visible, 
transient, and constantly changing, from its conversion into bone. 

In rachitis, this vascular subperiosteal tissue, not undergoing, or 
undergoing slowly and imperfectly, the osseous transformation, and at 
the same time increasing more rapidly than in health, under the irritat- 
ing influence of the rachitic disease becomes a thick layer. Its color 
and appearance are like spleen pulp, so that the older observers sup- 
posed there was a hemorrhagic extravasation between the periosteum 
and the bone. There is, however, no extravasation of blood, unless it 
accidentally occur from the numerous delicate capillaries. The resem- 
blance to extravasated blood, or spleen pulp, is due to the abundant 
growth of large and thin-walled capillaries from the under surface of 
the periosteum, as shown by the microscope. This vascular outgrowth 
is, for the most part, quite uniform over the diaphysis of the long bones, 
while upon the cranial bones its thickness is much greater in one locality 
than in another. The attempt at ossification also appears in this tissue. 
Lime-salts are scantily and loosely deposited through it, forming osteo- 
phytes — vascular and fragile — rather than true bone. 

The question naturally arises, How does rachitis affect bone which is 
already formed when the rachitic state begins ? Virchow's answer is 
the following : " Rachitis has . . . by more accurate investigation 
been shown to consist, not in a process of softening in the old bone, as 
it had previously been considered to be, but in a non-solidification of 
the fresh layers as they form; the old layers being consumed by the 
normally progressive formation of medullary cavities, and the new 
remaining soft, the bone becomes brittle." 1 It seems, however, from the 
experiments of Heitzmann, that this opinion should be modified, at 
least as regards rachitis produced by lactic acid. Moreover, in rachitic 
craniotabes, occurring in infancy, there is certainly bone absorption, 
for portions of the occipital and parietal bones are absorbed to cause 
the soft spaces. We must, therefore, believe that there is in rachitis 
more or less absorption of lime-salts in the bone, in addition to that 
required in the normal growth of medullary cavities and canals for 
vessels. 

In healthy bone, the earthy salts are in excess of organic matter, 
nearly in the proportion of two to one; but in rachitis the proportion 
is reversed, the organic matter being much in excess. The following 
table gives analyses of rachitic bones by Marchand, Davy, Boettger, 
and Friedleben : 





Femur. 


Bad 


us. 


Vertebra. 




Inorganic 


Organic. 


Inorganic. 


Organic. 


Inorganic . 


Organic. 


Case I. 
Case II. 
Case III. 
Case IV. 


20.60 
37 80 
20.89 
52.85 


79.40 

62.20 (conval ) 

79.11 
47.15 


21.24 
20.00 


78 76 
80.00 


18.68 
32.29 


81.32 
67.71 



1 Cellular Pathology, Chance's Translation, Lecture xix. 



ANATOMICAL CHARACTERS. 115 

As might be expected, the relative proportion of organic and in- 
organic matter varies greatly in different cases, and at different stages 
of the same case. In severe rachitis many bones are affected. It is 
stated that there is no bone in the entire skeleton that may not suffer, 
but in mild cases only a few are involved, at least to such an extent as 
to produce structural changes, appreciable to touch or sight. 

Pathology of Rachitis. — In this connection, it is proper to consider 
the pathology of rachitis. What is its nature ? Niemeyer, in my 
opinion, expresses the correct view, when he says "it seems to me that 
the most probable hypothesis regarding the cause of rachitis is that 
which refers it to inflammation of the epiphyseal cartilages and peri- 
osteum." The increased vascularity of the periosteum, the prolifera- 
tion of periosteum and cartilage, the tenderness and pain on motion, 
and the febrile movement in acute forms of the disease, indicate in- 
flammation rather than any other recognized pathological state. The 
rachitic inflammation as it affects the osseous system, appears to be of 
a chronic or subacute character, presenting an analogy with certain 
other well-known inflammations, such as cirrhosis and certain forms 
of chronic nephritis, in which proliferation of connective tissue and 
sclerosis occur. The eburnation rather than normal ossification, which 
terminates the rachitic process, may properly be considered an osteo- 
sclerosis. Comformably with the theory of the inflammatory nature 
of rachitis, the periosteum is found infiltrated and thickened, and of a 
reddish hue from hyperemia, and from the presence of the newly 
formed capillaries underneath, which have been described above as 
forming a layer of considerable thickness, known as the "germinal, 
vascular tissue." Moreover, as in inflammation, some secretion along 
with the vascular growth occurs over the bone from the under surface 
of the periosteum. The various interspaces in long, short, and flat 
bones, the diploe, cancelli, and interlamellar openings, contain a sub- 
stance similar to that exuded under the periosteum. It appears to be 
an inflammatory exudation. 

Anatomical Characters in the Stage of Deformity. — Rachitic 
bone, when the disease has continued for some time and is still in its 
active period, presents a bluish or dusky-red appearance, from its in- 
creased vascularity. After a variable time, weeks or months according 
to the severity of the disease, deformities begin to appear. 

Spiegelberg's description of the appearance of the rachitic foetus cor- 
responds for the most part with what I observed in the one whose skeleton 
is represented in Fig. 6. According to this writer, the body and limbs 
are plump : the latter short and curved ; the abdomen large and promi- 
nent ; and the head sometimes hydrocephalic. The skin is thick and 
loose, and the adipose tissue well developed ; the liver large ; the epi- 
physes swollen and soft ; the short and curved diaphyses sometimes 
broken. The rotundity of the thorax is preserved, and the sternum is 
not carried forward, since there has been no respiration ; the ribs, in 
softness and liability to fracture, correspond with the long bones of the 
extremities. The sternum, most of all the bones, shows the delay in 
ossification ; the clavicle is among those least affected. The cranium 



116 RACHITIS. 

may be represented by a membranous bag with plaques of bone, or the 
cranial bones may be formed and in shape, but thickened, and softened ; 
the sacral promontory is pressed forward and downward; the sacral 
vertebrae flattened ; the ilia flattened and widened, and the pubic arch 
increased. 

It is interesting to compare these deformities with those in the child, 
since they occur under conditions so very different. Rachitic bone 
seldom retains its normal form or shape; its projecting points are 
rounded, and as soon as it softens, it begins to yield to pressure exerted 
upon it. Hence the curvatures, so common and characteristic. The 
portion of a long bone which is formed after rachitis commences, con- 
tains so little earthy matter that it bends readily in its fresh state, 
either by muscular action or by the weight of the trunk, "in the 
manner," says Vogel, "of a quill or willow stick." The interior of the 
bone, which was formed before rachitis began, and which contains 
nearly or quite the normal proportion of lime, is apt to break instead 
of bending, but, as it is surrounded on all sides by the soft tissue, the 
fragments are not displaced, and probably do not crepitate. So scanty 
is the calcareous deposition in typical cases, that, says Trousseau, "the 
bones .... can be cut with a knife with as much ease as a carrot 
or other soft root," and the dried specimen weighs but from one-sixth 
to one-eighth as much as normal bone. One writer states that the 
dried rachitic bone is sometimes so porous, from the small amount of 
lime which it contains, that it is possible to respire through it, as 
through a sponge. 

In ordinary cases, the bones which exhibit most strikingly the rachitic 
change, and which, therefore, should be carefully examined in making 
the diagnosis, are the cranial bones, the ribs, and the radius — the sternal 
ends of the ribs, and the lower end of the radius. It is seldom that 
these bones do not give evidence of the disease, if it be present, and in 
greater degree than other bones. They are the first to be affected to an 
extent that is appreciable to the observer. 

Changes in the Cranial Bones. — In these bones interesting and im- 
portant alterations occur. Their edges, which correspond with the epi- 
physeal cartilages, undergo proliferation, and become thickened like the 
latter. This thickening, and the delayed union of the sutures, produce 
grooves, which can be traced by the fingers between the bones, and 
which are sometimes appreciable to the sight. Rachitis causes some 
enlargement of the cranium, but the enlargement seems greater than it 
really is, on account of the retarded growth of the facial bones. In a 
discussion on rachitis in the London Pathological Society, reported in 
the Lancet^ it was stated that in seventeen rachitic children, with an 
average age of 4.72 years, the average circumference of the head was 
21.22 inches, w T hile in the same number who were non-rachitic, and 
with an average age of 6.05 years, the average circumference was 19.95 
inches. 

The retarded ossification is manifested not only in the open sutures, 
but also in the large size and patency of the fo?itanelles, which are not 

1 Lancet, 1880, vol. ii. p. 1017. 



ANATOMICAL CHARACTERS. 117 

closed till long after the usual time. The anterior fontanelle should be 
closed between the fifteenth and twentieth months, but, in the rachitic, 
it remains membranous till after the second year, even into the third or 
fourth year. Since examination of the anterior fontanelle is important 
in determining whether or not rachitis be present, it should be borne in 
mind that, in the normal state, this space increases in size till the 
seventh month, w T hen it is at its maximum, and that after the ninth 
month it becomes progressively smaller. 

The shape of the rachitic head varies. In general, instead of its 
normal rounded form, it approaches a square shape. Another type is 
sometimes observed in which there is no marked angularity, but in 
which the antero-posterior diameter is enlarged. In the square head, 
the forehead projects, and both the frontal and parietal protuberances 
are unusually prominent. The sutures are depressed to a certain extent, 
as has already been mentioned, and the anterior, lateral, superior, and 
posterior surfaces of the cranium are more flattened than in health. The 
lambdoidal suture, which should close by the fourth month, and the 
sagittal, which should close by the end of the first year, have made 
little progress towards union when the second year begins. The undue 
prominence of the frontal and parietal bosses takes its origin from the 
exaggerated proliferation of the periosteal or fibrous covering of the 
bones. 

Oraniotabes. — Thinning of the cranial bones in places so that the 
brain lacks proper protection, has long been noticed in the examination 
of rachitic heads, but the injury that results to the infant was over- 
looked till pointed out by Dr. Elsasser. Craniotabes occurs for the 
most part in patients under the age of one year, and a large proportion 
are under eight months. Its occurrence in the foetus, as shown by a 
case published in the New York Obstetrical Journal in 1870, and by 
Heitzmann's case, has already been alluded to. The factors in pro- 
ducing this thinning are rachitic softening of the bones and pressure; 
pressure of the brain from within and of the pillow from without. Con- 
sequently, the portions of the cranial arch in which the thinning occurs 
are the posterior and lateral, the occipital bone and the posterior half 
of the parietal. If the infant lie chiefly on one side, in its crib, on this 
side the craniotabes occurs, while those portions of the cranium which 
are not pressed upon, as the frontal bone, exhibit no thinning. The 
soft spots are yielding w T hen pressed upon, and in the cadaver they are 
seen to be translucent w T hen held to the light. The amount of absorp- 
tion varies greatly according to the degree of rachitic softening, and 
the amount and continuance of the pressure. There may be in some 
instances simple depressions, like erosions in the bone, with a contin- 
uous but thin bony layer remaining; but in other cases, such as have 
been particularly examined and studied by physicians, the bone absorp- 
tion is complete over areas of greater or less extent, so that the peri- 
cranium and dura mater are in contact. In examining a child for 
craniotabes, it should be borne in mind that the margins of the bones, 
even when there is no thinning, but thickening from the cartilaginous 
proliferation, are flexible in the rachitic. The pressure must be made 
in a direction away from the sutures, to ascertain whether craniotabes 



118 RACHITIS. 

has occurred. The pressure should at first be made lightly and cau- 
tiously, with the fingers, for if there be total absence of bone, unless of 
very little extent, deep and forcible pressure might injure the brain, 
for so soft and delicate an organ, covered only by the scalp and dura 
mater, badly tolerates pressure. If the first examination detect no soft 
place, the fingers may be pressed more firmly against the scalp, when, 
if the bone be much thinned, so that there is only a small layer of the 
lime-salts underneath, it will be found to yield. The sensation com- 
municated to the fingers, when there is an open space in the cranium, 
and the dura mater and scalp are in contact, has been likened to that 
experienced when pressing upon a fully distended bladder. At a meet- 
ing of the London Pathological Society, reported in the Lancet for 
November 20, 1880, Dr. Lees presented statistics to show that cranio- 
tabes was one of the lesions of inherited syphilis ; but whether it may 
result from syphilis or not, the evidence that there is a cranial softening 
which is strictly rachitic, appears, from repeated observations, to be 
sufficient. 

Symptoms of Craniotabes. — As craniotabes gives rise to peculiar 
symptoms quite distinct from those of the general rachitic disease, they 
may be properly considered in this connection. Craniotabes usually 
occurs during the first year of infancy, and most frequently prior to 
the tenth month. The brain at this age is soft and yielding, since it 
contains a large percentage of water. Unless handled with care at an 
autopsy, it is readily lacerated, and moderate pressure upon it is seen 
to disturb and move it at a considerable distance from the point of con- 
tact. It assists to a proper understanding of the symptoms of cranio- 
tabes to recall to mind the fact, well known to surgeons, that slight 
depression of even a small portion of the skull is apt to produce grave 
symptoms. It is not surprising, therefore, that craniotabes, when there 
is a space of considerable size in the cranial arch destitute of bone, is 
attended by symptoms due to the mechanical effect of external pressure, 
whenever a substance less yielding than the brain comes in contact with 
the unprotected part. 

Since pressure from the pillow without, and from the brain within, is 
believed to be the cause of the absorption, the craniotabes must obviously 
occur in the posterior and postero-lateral portions of the cranium. 
Corresponding with this explanation of the causation, the thinning 
actually occurs in the occipital and posterior portions of the parietal 
bones, while the anterior halves of the parietal bones, and the frontal 
bones, are even thicker than normal, from the cartilaginous and perios- 
teal proliferation occurring along the sutures and on the surface of these 
bones, as already described. It is well known that long-continued 
pressure produces absorption of calcareous matter even more readily 
than of soft tissues, as is shown in the absorption of a tooth of the first 
set by the growth of the dental pulp of the second set. In the normal 
growth of the skull, constant absorption of the under surface of the 
cranial bones is going on to make room for the enlarging brain, and 
when no calcareous deposition occurs upon the external surface to com- 
pensate for the loss within, we might expect even a greater amount of 
craniotabes than ordinarily occurs. 



ANATOMICAL CHARACTERS. 119 

Every rachitic infant is fretful, but one with craniotabes is especially 
so, if the open spaces be of considerable size. If it lie upon the pillow, 
in its accustomed manner, as is most natural for it, the unprotected 
portion of the brain may be so pressed upon by the weight of the head, 
that it feels uncomfortable. It does not have quiet sleep, probably 
because the cerebral circulation and functions are in a measure dis- 
turbed ; it is apt to awaken readily and often, and frets till it is taken 
in the nurse's arms. Sometimes it instinctively seeks a position on the 
edge of the pillow, with the face downwards, and it becomes more quiet 
when resting over the nurse's shoulder with the face backward. But 
if fretfulness, disturbed sleep, and the necessity of closer attention on 
the part of the mother and nurse were the only ill-effects of craniotabes, 
it would possess much less pathological significance than pertains to it. 
Pressure upon so delicate and important an organ as the brain, involves 
risks and produces serious symptoms in proportion to its degree. Even 
a slight injury of the skull which produces depression, though it may 
be of trifling amount, will cause serious forms of nervous disorder. So 
craniotabes is believed to sustain a causative relation in certain cases to 
one of the most dangerous of the neuroses, namely, laryngismus 
stridulus, an affection which is also designated "internal convulsions," 
"spasm of the glottis," and " Kopp's asthma," although Kopp was not 
the first to describe and recognize the malady. The etiology of this 
neurosis has not been fully elucidated. It is certain that a large pro- 
portion of those who suffer from it are rachitic, and that it is more 
common and severe where rachitis is prevalent, as in England, than 
where it is rare, as in the rural districts of America. It is not often 
the cause of death in this country, and the fatal cases that do occur are 
only seen in cities, whereas in parts of Europe, where rachitis is much 
more common than with us, it causes many deaths. 

Certain infants, when in a state of excitement, have what are termed 
"holding-breath spells." The face is flushed, and breathing ceases for 
some seconds, after which respiration returns and is normal. These 
attacks are unimportant, but they appear to be the same in nature with 
the more severe and dangerous seizures of laryngismus stridulus. They 
have no pathological significance, excepting as they show the same 
neuropathic state as that in laryngismus, and as they may be precursors 
of this disease. Laryngismus stridulus, or glottic spasm, is usually 
preceded by more or less impairment of the general health, and often 
by fretfulness, which is characteristic of the rachitic state ; but the 
attack occurs suddenly, without premonition and is of short duration. 
It begins with an arrest of respiration, a true apnoea, as if from 
paralysis of the respiratory centre in the medulla. The lips may be 
livid ; a pallor spreads over the face ; sometimes more or less rigidity 
of the limbs occurs, with carpo-pedal contractions, and after a few 
seconds, a quarter or a half minute, a long and deep but difficult inspi- 
ration through the narrow chink of the glottis follows, accompanied in 
many patients by a whistling or crowing sound, and the attack ends 
with, perhaps, a momentary look of bewilderment, or dread, on the 
child's face. Now this disease, like eclampsia, does not have a uniform 
causation. In certain cases, it appears to be a reflex phenomenon, due 



120 



RACHITIS. 



to an irritant in some part of the system, as in the intestines; but 
many observations have established the fact that rachitis, also, sustains 
a causative relation to it. A large proportion of the infants affected 
with laryngismus exhibit unmistakable rachitic signs, and, in the 
opinion of many experienced observers, the exposed state of the brain 
affords explanation of the fact that so many of the rachitic have this 
neurosis. Still from observations which I have made, and from those 
of other observers, like Senator, it is certain that laryngismus stridulus 



Fig. 7. 




Head of a rachitic child in the New York Infant Asylum. 



is common in the rachitic who do not have craniotabes, so that there 
must be a causative relation in rachitis to laryngismus independently of 
the cranial softening. The accompanying woodcut represents the rachitic 
head of a child in the New York Infant Asylum. This patient had 
also attacks of laryngismus stridulus. 

Changes in the Vertebra?, etc. — The short bones which participate 
in the rachitic disease, become softer and more* yielding, and their 
cancelli are filled with a reddish pulpy substance. In many rachitic 
cases, the vertebrae are but slightly involved, so that no deformity of 
the spinal column results ; but occasionally, when many bones are 
affected, the vertebrae and intervertebral cartilages soften, and spinal 
curvatures result. The curvatures are due to the weight of the shoulders 
and head on the spinal column. They are, with some deviations, an 
exaggeration of those present in the normal state. Rachitic curvatures 
of the spine are, therefore, mainly antero-posterior with some lateral deflec- 
tions. Where there is much curvature, the vertebrae become wedge- 
shaped, narrowed upon the concavity, and thickened upon the convexity. 
The intervertebral cartilages are also more or less changed by the press- 
ure, being thinned where the vertebrae approximate to each other, on 
the concave aspect of the curvature, and of normal thickness or thicker 



ANATOMICAL CHARACTERS 



121 



than normal upon the convexity. The accompanying woodcut exhibits 
the nature and appearance of rachitic spinal curvature in the adult. 
Rachitis having occurred at the usual age, resulted in the permanent 
deformity here illustrated. In extreme cases, fortunately rare, the 
functions of important organs may be seriously impaired by the curva- 
ture and consequent compression, as in Pott's disease. Thus, according 
to Miller, the aorta has been so doubled upon 
itself as to diminish materially the flow of Tig. 8. 

blood to the lower extremities, and sensibly 
impair their nutrition. The effect of so 
great curvature upon the functions of the 
heart and lungs must obviously be detri- 
mental. 

At first the spinal curvatures disappear 
when the child reclines, or is lifted by the 
axillse, so as to raise the head and shoulders 
from the spine, but when the deformity has 
continued so long that the vertebrae and car- 
tilages have become wedge-shaped, it remains 
for life, or can only be rectified slowly and 
with difficulty by mechanical appliances. As 
seen in the woodcut, the common curvature 
in the dorsal region is backward (kyphosis), 
while to compensate the patient instinctively 
carries the neck forward, with the head 
thrown back, causing cervical lordosis, a 
similar anterior curvature being common in 
the lumbar region. Lateral curvature (sco- 
liosis) may or may not be present, even when 
there is considerable antero-posterior flexure. 
Scoliosis is sometimes produced by the nurse, 
in carrying the infant habitually over one arm. 

Changes in the Maxillce. — Fleischmann has investigated the changes 
which rachitis produces in the maxillary bones. Stunted growth of the 
facial bones, generally, has long been known, and has been remarked 
upon by various writers ; but, according to Fleischmann, other interest- 
ing changes occur in the jaw-bones, which affect the direction and 
position of the teeth. According to this author, the arched shape of 
the lower jaw becomes polygonal, and the direction of the alveolar pro- 
cess also changes, so that it inclines inward. This deviation in the arch, 
and in the alveolar process, which begins in the region of the canine 
teeth, necessarily causes shortening of the lower jaw. Commencing 
soon after, a change is observed in the upper jaw-bone from the zygo- 
matic arch forward, so as to cause lengthening of this bone, changing 
here also the shape of the arch and the position of the teeth. The 
lateral incisors, instead of being in front, have a lateral position, and 
the incisors and molars diverge, so that when the jaws are closed they 
overlap the corresponding teeth of the lower jaw in front and upon the 
sides, a condition the opposite of that seen in the jaws of old people. 
Fleischmann attributes these changes in the lower jaw to the action of 




Rachitic spinal curvature in an 
adult. (From a specimen in the 
Wood Museum, Bellevue Hospital.) 



122 RACHITIS. 

the masseter and mylohyoid muscles, and perhaps the genio-glossus, 
and to pressure of the lip, the deficiency of earthy salts in the bone 
rendering it more easily acted on by the muscles. The change in the 
upper jaw-bone he attributes to lateral pressure of the zygomatic arches. 

Changes in the Ribs. — The ribs are early affected in rachitis. The 
swelling of their anterior ends, where they unite with the costal carti- 
lages, producing the " rachitic rosary," has been already alluded to as 
one of the first and most conspicuous signs of rachitis. The costo- 
chondral articulations are enlarged in all directions, appearing as nodules 
under the skin. If an opportunity occur of inspecting, at an autopsy, 
the pleural surface, the nodular prominences are seen to be even greater 
and more distinct there than under the skin. 

The deformity of the thorax consequent upon softening of the ribs is 
interesting. Commencing with the spine, the ribs extend nearly di- 



Fig. 



Rachitic child with characteristic deformity of head, ribs, and radius. (From a patient in the New 

York Foundling Asylum ) 

rectly outward ; at the union of the dorsal and lateral regions, they make 
a short curve forward, and then turn inward, also with a short curve 
toward the sternum (Fig. 10). This abrupt bending of the ribs, which, 
in their softened state, has been caused by atmospheric pressure during 
respiration, produces a depression in the thoracic wall at about the 
point where the ribs and their cartilages unite. A groove extends on 
the antero-lateral surface of the thorax from the second or third rib 
downward, and a little outward. Sometimes the bottom of the groove 
is occupied by the costo-chondral joints ; in other cases these joints are 
a little to one side of the deepest part of the groove. The transverse 
diameter, therefore, of the anterior half of the thorax is much less than 
in health. This necessarily diminishes the lateral expansion of the 



ANATOMICAL CHARACTERS 



123 



lung in inspiration, and causes unusual prominence of the sternum. 
Hence the expressions "pigeon-breasted," "resemblance to the prow 
of a ship," etc., applied to this deformity. The presence of the heart 
renders the groove more shallow on the left side, at the fourth and fifth 
ribs, than on the opposite side, since this organ affords partial support 
to the chest-wall. On the other hand, the right groove is not as long 
as the left, as the lower ribs on this side are partially supported by the 
liver. On both sides, however, the lower part of the thorax, that below 
the seventh, eighth, or ninth ribs, widens, being pressed outward and 
supported by the abdominal viscera. There is, therefore, in addition 
to the longitudinal groove, an antero-posterior depression, sometimes 
also spoken of as a furrow or groove, on either side, lying between the 
sixth and ninth ribs. 

The ribs with their attached muscles are important agents in respira- 
tion, but the soft and yielding nature of the ribs, in the rachitic, retards, 

Fro. 10. 




Deformity of chest in rachitis. 



and to a great extent prevents, the lateral expansion of the thorax which 
is necessary for normal and full inspiration. The action of the respira- 
tory muscles, and the pressure from within of the air descending along 
the air passages, is not sufficient to overcome fully the external atmos- 
pheric pressure, in the absence of proper resiliency of the ribs. Con- 
sequently, with each inspiration, we observe more or less sinking in of 
the thorax on either side, just as when a moderate obstruction to the 
entrance of air exists in the larynx or trachea. As the ribs become 



124 



KACHITIS 



firmer from the deposit of lime-salts, respiration is more regular and 
normal. 

Changes in Bones of Ujyper Extremity. — Although swelling of the 
lower end of the radius (see Fig. 9) is one of the earliest signs of 
rachitis, the bones of the upper extremities are less frequently curved 
and distorted than those of the lower extremities. The clavicle some- 
times softens and bends, producing two curvatures, one backward, near 
the scapula, and another of larger size nearer the sternum, directed 
forward and a little upward. Careful examination shows, in some 
rachitic patients, thickening of the margins of the scapula, like that of 
the cranial bones. The humerus is occasionally bent, and usually at 
the point of insertion of the deltoid, in consequence of the powerful 
action of this muscle in raising and supporting the arm. The radius 
and ulna are bent outward and twisted. The deformity is attributed 
by Sir. William Jenner to the fact that ricketty children support them- 
selves, while in the sitting posture, upon the palms of the hands pressed 
upon the floor or couch. Supporting the weight of the body in this 
way not only, in his opinion, causes bending of the ulna and radius, but 
also aids in producing the deformities of the humerus and clavicle. 

Changes in Bones of Pelvis. — The deformities of the pelvic bones, 
resulting from rachitic softening, are, in the female infant, the most im- 
portant of any which the skeleton undergoes. They are produced by 



Fig. 11. 



Fig. 12. 



Fig. 13. 




Kachitic deformities of the pelvis. (From specimens in the Wood Museum.) 



pressure from above of the abdominal organs, serving to widen the brim 
of the pelvis, and also by pressure of the spinal column, sustaining the 
weight of the trunk, shoulders, and head, pressing forwards the pro- 
montory of the sacrum, in the sitting posture, and thus diminishing the 
antero-posterior diameter of the pelvic brim. There is, moreover, two- 
fold pressure from below, that caused by the heads of the thigh-bones, 
in standing, and that exercised by the tuberosities of the ischia, in sit- 
ting. Both these forms of pressure have a tendency to narrow the out- 
let of the pelvis. Hence the marriage of the female who has been 
rachitic in infancy may involve serious consequences. Many of the 



ANATOMICAL CHARACTERS. 125 

tedious instrumental labors in the families of the city poor, which 
severely tax the patience and endurance of young practitioners, are at- 
tributable to rickets in early life. 

Changes in Bones of Loiver Extremities. — The curvature of the 
femur is usually forward, or forward and outward. The neck of the 
femur sometimes bends by the weight of the body, or by use of the legs, 
so that the angle which it forms with the shaft is changed. The an- 
nexed woodcuts show the rachitic bend of this bone in an adult, years 
after rachitis had ceased, and when the bone had become consolidated 
by the new deposition of lime-salts. 

The curvature of the tibia and fibula varies. In those under the age 
of one year, it is apt to be outward, so that the knees are separated from 

Fig. 14. Fig. 15. 




Rachitic deformities of the femur (Wood Museum.) 

each other. In those old enough to stand, the weight of the body 
usually determines a forward bending of these bones. In one case in 
my practice, an anterior curvature so abrupt that an angle of about 70° 
was formed, existed about four inches above each ankle. This patient, 
though old enough to walk, almost constantly sat during the day with 
the feet extended beyond the sofa, so that the edge of the latter corre- 
sponded with the concavity of the legs. It seemed to me that the 
weight of the feet must have been a factor in causing these curvatures, 
especially as the case was one of very marked rachitic softening of 
different bones. Still, tibial and fibular bending at this point has been 
noticed by different observers, who have attributed it to the weight of 
the body in walking. Various other curvatures, besides those men- 
tioned, occur in the bones of the lower extremities, the direction in 
which the limbs bend being determined by the particular circumstances 
of the case. 

In mild cases of rickets, most of the deformities described above are 
lacking, but in typical cases certain of them stand out prominently, so 
as to be readily detected by one familiar with the disease. In all such 
cases the diagnosis is easy beyond that of most other maladies, for the 
changes which occur are not only conspicuous, but pathognomonic. 

Rachitis produces another important effect on the skeleton. Its 
growth is stunted, not only during the rachitic period, but subse- 
quently, so that those who have been rachitic in childhood, unless very 
mildly, have less than the average stature in adult life. The stunted 
growth is apparent, though ample allowance be made for curvatures. 
The arrest of development is greater in some bones than in others. It 
is greatest in the bones of the face, pelvis, and lower extremities. 



126 



RACHITIS 



Stunted growth of the pelvic bones of the female infant conjoined with 
the deformities alluded to above, may seriously affect her subsequent 
life, and a rachitic pelvis in the female, exhibiting both stunted growth 
and deformity, constitutes a valid reason for avoiding marriage. As a 



Fig. 16. 



Fig. 



Rachitic deformities of the femur, tibia, and fibula. (Wood Museum.) 

rule, the older the child is when rachitis begins, the less is the skeleton 
affected, and the less consequently is the deformity. 

Effect of Rachitis on Dentition. — As might be expected from the 
nature of rachitis, dentition is delayed. If the disease show itself 
before any tooth has appeared, the first teeth, to wit, the lower central 
incisors, will probably not appear before the ninth or tenth month, or 
even later. Sir Wm. Jenner considers the non-appearance of a tooth 
by the ninth month, with few exceptions, a sign of rachitis. Teeth 
which appear during the rachitic state are frail, deficient in enamel, 
and crumble readily. They become carious, rot, and break before the 
usual time. If certain teeth have appeared when rachitis begins, 
several months elapse before others cut the gum. It is even said that a 
child who has rachitis severely may never have a tooth, may remain 
toothless for life; but I have never observed such a case. Ordinarily, 
when the rachitic state ceases, and the health is fully restored, dentition 
goes on as before. The arrest of teething, so easily observed, has long 
been considered one of the most reliable diagnostic signs. The physi- 
cian cannot justly pronounce on the nature of the disease in a case of 
suspected rachitis, unless he first carefully inspects the gums. 



ANATOMICAL CHARACTERS. 127 

Changes in the Soft Tissues. — Although the conspicuous lesions of 
rickets pertain to the skeleton, the soft tissues are also more or less 
implicated. The ligaments become relaxed and flabby, giving unusual 
mobility to the joints, and unsteadiness to the movements. The fibrous 
bands which unite the vertebrae, as well as the ligaments of the ex- 
tremities, participate in the relaxation. In certain patients, the muscles 
throughout the system, partly, perhaps, in consequence of the gastro- 
intestinal disturbance, indigestion, and malnutrition ; partly, perhaps, 
from want of use (for the rachitic are apt to be quiet), become shrunken 
and flabby. The spleen is frequently enlarged, as ascertained by pal- 
pation and percussion. Bitter von Bittershain found this organ deci- 
dedly enlarged in ten out of thirty-five cases which he examined after 
death. The enlargement is the result of cellular proliferation, common 
in diseases which are attended by dyscrasia. The liver in many patients 
undergoes no perceptible change, except that it may be pushed a little 
downwards. It is occasionally found enlarged from fatty infiltration, 
but no special significance attaches to this, for fatty liver is common in 
various forms of disease attended by innutrition and wasting. It is 
common in tuberculosis, and in protracted intestinal catarrh, and its 
pathological significance appears to be the same in these various diseases. 
There can be little doubt that Sir Wm. Jenner errs when he states that 
albuminoid infiltration of the liver is common in rachitis. Parry, Gee, 
Dickinson, and Senator agree that it is rare, and that if it does occur, 
it is by coincidence. 

In a discussion on rachitis, in the London Pathological Society, Dr. 
Dickinson 1 spoke of enlargement of the spleen, liver, and lymphatic 
glands, which he had observed in rachitic cases. According to him, 
the spleen undergoes the greatest enlargement, the lymphatic glands 
the least, and, of the latter, a the mesenteric glands show the most 
decided swelling." The spleen in some patients has been so large that 
it occupied the greater part of the left half of the abdominal cavity, but a 
less degree of enlargement is the rule. The liver is apt to extend one or 
two inches below the ribs. The swelling, Dr. Dickinson adds, is not 
amyloid. " There is no new growth or deposit, only an irregular 
development of the proper tissues of the organs." He believes that 
both the corpuscular and interstitial elements are increased in the liver, 
spleen, and lymphatic glands. But other members of the Society had 
observed this enlargement only in occasional cases, and they considered 
it due rather to the state of health which caused rachitis than to rachitis 
itself. Dr. C. Hilton Fagge stated that he had failed to find swelling 
of the liver, spleen, or lymphatic glands, in a large majority of cases. 2 
An undue development of the lymphatic glands from hyperplasia is very 
common in children in various states of ill-health, and the mesenteric 
glands are especially apt to become enlarged from this cause in protracted 
cases of intestinal catarrh or irritation. 

The abdomen is protuberant from various causes. The lateral 
depression of the thoracic walls causes the liver and spleen to descend 
a little lower in the abdominal cavity than natural. The enlargement 

1 Lancet, December 11, 1880. 2 Lancet, November, 20, 1880. 



128 RACHITIS. 

of the liver and spleen, the feeble tonicity of the intestinal muscular 
fibres, and consequent distention of the intestines with gas, and the 
rachitic shortening of the spinal column, which causes approximation 
of the ribs and pelvis, necessarily produce abdominal protuberance. 

The kidneys themselves are not diseased in rickets, but there is an 
exaggerated discharge of phosphates in the urine, and, as stated above, 
lactic acid and free phosphoric acid have been found in this excretion. 
The urine is commonly pale ; its urea and uric acid are diminished ; 
and it sometimes contains a sediment of oxalate of lime. 

The brain is usually well developed, and appears healthy, with the 
normal proportion of white and gray substance. In one case the weight 
of this organ was ascertained by Dr. Gee to be fifty-nine ounces, and 
in another forty-two and a half ounces. In both brains the proportion 
of white and gray substances, and their color and consistence, seemed 
normal. 

Anatomical Characters of the Third Stage, or that of 
Reconstruction. — This stage will be better understood, if we recollect 
what has occurred during the first and second stages. The very 
vascular periosteum is drawn tightly over convexities, the pressure upon 
which diminishes the hyperaemia and the amount of exudation under- 
neath. Over the concavities the periosteum is loose ; it is hyperaemic, 
with abundant new capillaries, the interspace between it and the bone 
being filled with the gelatiniform substance already described. The 
reparative process goes forward more rapidly, and the deposition of 
lime-salts is more abundant upon the concave surfaces, where there have 
been free exudation and no compression of the capillaries, than elsewhere. 
The lime-salts are deposited from the blood. Consequently, from the 
increased capillary circulation and hyperaemic state of the periosteum 
produced by rachitis, the chalky matter is rapidly effused wherever 
there is an open space under the periosteum, and where the capillaries 
are in a state of engorgement. Hence the reconstructed bone is thicker 
and firmer upon the concave aspect of the long bones than elsewhere, 
and thinnest upon the convex aspect where the periosteum is more 
tense, and its capillaries more or less compressed. 

It is a question whether true ossification occurs at first during the 
reparative stage. The deposition of chalky matter is designated by 
some writers as a petrifaction rather than a 'true bone-formation. 
Trousseau likens it to the formation of callus after a fracture. It cer- 
tainly produces a substance more compact than ordinary bone. The 
term " eburnation " has been applied to this new osseous formation, and 
I have designated it " osteo-sclerosis." Some years since I examined 
microscopically an adult bone which exhibited the rachitic curvature in 
a marked degree, and was very hard. It contained the elements of 
true bone, but I was in doubt whether the part examined was formed 
during convalescence from rickets, or in the subsequent growth. 

Recovery from rickets is gradual. Little by little, the cartilaginous 
and periosteal proliferation ceases, the hyperagmia abates, and the bone- 
producing tissues return to their normal state. Certain of the defor- 
mities are permanent, but others disappear in the further growth of the 
skeleton. 



SYMPTOMS. 129 



Symptoms of Rachitis. 



Preceding and accompanying rachitis, symptoms may be present 
which are due to indigestion and intestinal catarrh, such as flatulence, 
unhealthy stools, and poor or capricious appetite. When rachitis 
begins, the infant becomes fretful ; its sleep is apt to be restless and 
disturbed, and it awakens often. It repels attempts to amuse it, and is 
apparently annoyed by them. Nurse and mother speak of it as a cross 
child. It perspires . freely from the head and neck, both when awake 
and when asleep, while the extremities and trunk are dry. Its pillow 
is wet with perspiration during sleep, and sweat drops may be seen upon 
forehead and face. If the surface be dry, a little excitement or eleva- 
tion of temperature causes the perspiration to appear. The rachitic 
child does not well tolerate the bedclothes, and attempts to throw them 
off from its limbs, even in cool weather, lying exposed, and causing 
considerable annoyance to the nurse, who strives to prevent its taking 
cold. Sometimes miliaria, due to the moist state of the skin, appear 
upon the face and neck. The subcutaneous veins which return blood 
from the head are large, and the jugular veins full. 

Another symptom is soon observed, to wit, tenderness over a con- 
siderable part of the surface, perhaps largely due to the morbid state 
of the periosteum over so many bones, though it is also experienced 
when pressure is made upon the soft parts of the abdomen. The ten- 
derness is probably, in part, the cause of the fretful disposition. The 
little patient appears to dread to be touched ; its flesh is sore ; it repels 
attempts to amuse it, and wishes to be quiet. Dandling it upon the 
arms, swinging it, or even walking with it, which delights the healthy 
child, and elicits a smile or notes of glee, only adds to its discomfort. 
It is most at ease when left alone, upon a soft cot or pillow, or, if it 
have craniotabes, when quietly held over the shoulder. Languor, dis- 
inclination to use the limbs, or to play, moderate thirst, with other 
symptoms referable to the digestive apparatus, which are present in 
many cases, and which have already been described, are soon followed 
by changes in the skeleton, which are perceptible to the sight and on 
palpation. The pulse and temperature, in a large proportion of the 
ordinary chronic cases, do not deviate from the healthy state, except 
that in some patients there is a slight febrile movement in the latter 
part of the day. 

Although rachitis is ordinarily a chronic disease, insidious in its 
commencement, gradual and progressive in its development, occupying 
months, there is an acute form which is attended by more marked febrile 
movement and tenderness, and in which the articular swelling appears 
more quickly. 

A bruit de soufflet, of greater or less intensity, synchronous with the 
pulse, has frequently been heard in rachitic cases by applying the ear 
over the anterior fontanelle, Drs. Whitney and Fischer, New England 
physicians, first called attention to this murmur, believing it to be a 
sign of chronic hydrocephalus. MM. Rilliet and Barthez heard it in 
cases of rachitis, and, therefore, concluded that the American physicians 

9 



130 rachitis. 

had confounded the two diseases. More recent observations have 
established the fact that this bruit has little diagnostic value. It is 
heard whenever there is sufficient patency of the anterior fontanelle, 
both in health and disease, for sound is conducted better through a 
membrane than through bone. Dr. Wirthgen heard the bruit in 22 
out of 52 children, of whom all except four were in good health. I 
have auscultated the anterior fontanelle in 29 infants, who were with 
two exceptions between the ages of three and thirty months. All were 
well, or having merely trivial ailments which did not affect the cerebral 
circulation. In most of them a murmur could be distinctly heard, 
synchronous with the respiratory act, and in 15 of the 29 cases no 
other sound could be detected, while in the remaining 14 a bruit could 
be detected, synchronous with the pulse. 



Complications and Sequelae of Rachitis. 

These have been in part described in the foregoing pages, out there 
are certain other results of the disease to which it is proper to call atten- 
tion. If the deformity in the thoracic wall, namely, the lateral depres- 
sion of the ribs and anterior projection of the sternum, be great, we 
would naturally expect that the two important organs underneath, the 
heart and lungs, would receive some detriment. Upon the surface of the 
heart, at the point where it supports the softened ribs, a white patch is 
often found, due to thickening of the pericardium and proliferation of 
the endothelial cells, just as thickening of the skin in the palm of the 
hand occurs from friction and pressure upon that part. It is probable 
that this pressure does not seriously impair the function of the heart, 
but it may increase the weakness of its movements in any asthenic dis- 
ease which may occur during the rachitic period. The injury sustained 
by the lungs is greater and more apparent. If the ribs be flexible, 
and much depressed, full inflation of the lung cannot occur in those 
parts where the depression is greatest. Semi-collapse of certain lobules 
is apt to occur, and even complete collapse of the thin edges of the lung. 
The stress of respiration falls unequally upon different parts of the 
lung. The anterior portion, which ascends with the sternum as that is 
propelled forward, is more fully dilated than the' lateral and posterior 
parts, and hence is apt to become emphysematous. If in this state of 
the thorax and lungs, severe bronchitis or broncho-pneumonia arise, the 
state is one of great peril. The mucus and pus being expectorated with 
difficulty, clog the tubes and produce dyspnoea. Full inspiration m the 
lateral and depending portions of the lung, which is required in order 
to expel these secretions, not occurring, the result may be unfavorable, 
even in comparatively mild forms of inflammation. Bronchitis and 
bronchopneumonia are the causes of death in not a few cases of severe 
rickets. Certain writers state that chronic hydrocephalus, diarrhoea, 
and eclampsia may complicate rachitis. I have not seen any case in 
which rickets seemed to sustain a causative relation to either hydroce- 
phalus or diarrhoea, but we know that diarrhoea frequently precedes and 
accompanies rachitis, and its relation to it is that of cause rather than 



DIAGNOSIS. 131 

effect. This subject has been sufficiently treated of in preceding pages. 
Rachitic infants appear to be more liable to eclampsia than those who 
are healthy. This would be inferred from their liability to laryngismus 
stridulus, a neurosis whose pathology is similar to that of eclampsia. 



Diagnosis of Rachitis. 

Rachitis in many instances continues a considerable time before its 
nature is suspected, the symptoms to which it gives rise being over- 
looked, or attributed to other causes than the true one ; and yet it is 
important that an early diagnosis be made, for it is much more amen- 
able to treatment in its early than in its later stages. The deformities 
which mar the beauty, and to a certain extent impair the activity and 
usefulness, of so many who have been rachitic in childhood, may often 
be prevented by early diagnosis and treatment. Many with this disease 
do not show the usual signs of faulty digestion and innutrition, espe- 
cially on casual inspection, for there may be considerable adipose de- 
velopment and rotundity of features and form in a rachitic child ; while, 
on the other hand, there are numerous instances of malnutrition and 
wasting without rachitis. Early diagnosis, when the affection is of a 
mild type, is necessarily difficult, but a watchful and painstaking phy- 
sician Avill commonly detect the disease before it has run many weeks, 
if he bear in mind its frequency, and carefully examine the patient. 

If called to a suspected case, we should inquire into the history and 
particularly whether there have been signs of intestinal catarrh or in- 
nutrition. The gums should be inspected to ascertain whether there 
is backwardness in dentition, and the head, to note its shape and size, 
whether it is elongated, or whether it approximates the square shape, 
with broad forehead and large protuberances. We should notice also the 
state of the fontanelles and sutures, and whether softening and thinning 
of the cranial bones be present. The costo-chondral articulations and 
those of the wrist, should also be carefully examined to ascertain if 
there is any enlargement, and the shape of the thorax, which begins 
to exhibit the rachitic deformity at an early stage of the disease, should 
likewise be noticed. We should also examine the child in reference to 
other less prominent signs, such as spinal curvature, abdominal pro- 
tuberance, muscular weakness, and relaxation of ligaments (which pro- 
duce feeble and unsteady use of the limbs), perspirations upon the head 
and neck from slight excitement, and during sleep, fretfulness, etc. If 
rachitis be present, certain of these signs will be observed. 

The late Dr. Parry called attention to the importance of making a 
differential diagnosis between the pseudo-paraplegia of rachitis and true 
paraplegia, which is the prominent symptom of infantile paralysis. The 
rachitic child, from muscular weakness and ligamentous relaxation, and 
from the soreness and tenderness common in this condition, may seldom 
use his legs ; may sit or lie quietly at the age when healthy children, 
if awake, are constantly moving their limbs. If we attempt to make 
him walk or stand, his legs may be so limp and powerless that they 
give way under his weight, but this is a different state from paralysis. 



132 RACHITIS. 

In paralysis, the fault is in the nervous system — usually in the nervous 
centres — whereas, in rachitis, it is in the muscles and ligaments. The 
rachitic child, when sitting or lying down, readily moves his legs if his 
feet be tickled or pinched, while the paralyzed limb responds to the irri- 
tation imperfectly. In infantile paralysis, the loss of muscular power 
is, with few exceptions, confined to the muscles of the lower extremities; 
but in rachitis, the muscular feebleness is more general, being notice- 
able in the arms as well as in the legs. Great relaxation of the ligaments 
is in most instances due to rachitis. It is especially noticeable in the 
ankle and knee-joints, and is a diagnostic sign which should not be over- 
looked in the examination of a suspected case of the disease. 



Prognosis of Rachitis. 

The prognosis of rickets is usually favorable, provided that no serious 
complication arises. Rachitis is not in itself fatal, under ordinary cir- 
cumstances. If there be much lateral depression and narrowing of the 
thorax, the functions of the heart and lungs may be embarrassed, and 
if the patient have a severe bronchial catarrh or broncho-pneumonia, 
the condition becomes one of danger. Rachitic children seem to be 
especially liable to catarrhal attacks of the air-passages, and even a 
moderate catarrh, with a deformed thorax, may prevent proper decar- 
bonization of the blood, and cause lividity and dyspnoea. Therefore, 
now and then, a rachitic child succumbs to an attack of inflammation 
of the respiratory apparatus, which would not have been fatal if there 
had been no rachitic deformity. We have seen that in whatever way it 
may act to produce this form of spasm, rachitis is a cause of laryngismus 
stridulus. Occasionally spasm of the glottis is fatal, but cases with 
such a termination are rare in America, though not infrequent in some 
European countries. 

Of the diseases of childhood which rachitic children tolerate badly, 
and w 7 hich may prove fatal in consequence of rachitic bone-softening 
and deformity, pertussis should be mentioned, If this be severe while 
the ribs are soft and yielding, and there be lateral depression of the 
thorax, the spasmodic cough produces great suffering and involves 
danger. Lividity, feeble action of the heart, pulmonary and cerebral 
congestion, and eclampsia, may occur. Measles, if it be attended by 
considerable bronchitis, and especially if it be complicated by broncho- 
pneumonia, is also one of the dangerous intercurrent diseases. The 
gravity of these inflammations of the respiratory apparatus is usually 
proportionate to the degree of recession of the ribs during inspiration. 
With these exceptions, and with that of risk to the married female who 
has deformity and stunted growth of the pelvic bones, the rachitic are 
not liable to any ulterior serious consequences. Minor deformities, in 
mild cases, not infrequently disappear in the subsequent growth of the 
skeleton. The older the child is when rachitis begins, the milder is 
ordinarily the form of the disease, and the more speedy, consequently, 
the recovery, and the less the deformity. In the gravest cases, the 
disease will almost always be found to have begun under the age of one 
year. 



TREATMENT. 133 



Treatment of Rachitis. 



Since rachitis sometimes develops in the foetus it is important, in 
order to prevent this malady, that the parentage be healthy. The 
pregnant woman should lead a quiet and regular life, with sufficient ex- 
ercise to produce healthy digestion, but without too arduous work, and 
with regular meals and wholesome diet. By the observance of such 
rules foetal rachitis might probably, in most instances, be prevented. 
Most cases of rachitis, however, commence in infancy, so that by proper 
management of the infant, we may hope to prevent, and usually can 
prevent the occurrence of this disease. 

The correct treatment of rachitis is apparent when we consider its 
character and the nature of its causes. The obvious indication is to 
restore healthy nutrition. This requires both hygienic and therapeutic 
measures. The apartment in which the child resides should be dry, 
airy, and plentifully supplied with light. He should be taken daily 
into the open air, in order to invigorate his system, but in such a way 
as not to increase his suffering, on account of his general tenderness. 
Residence in the country is far preferable to that in the city, because 
of the better hygienic conditions which it procures. The purer air, the 
better diet, and consequently the more robust development gained by 
rural life, are important advantages, to obtain which is abundantly 
worth pecuniary sacrifice when the children of a family are rachitic. 

The diet in rachitis should receive particular attention, since indiges- 
tion and gastro-intestinal derangement sustain a causative relation to so 
many cases. Good breast-milk ought, if possible, to be obtained until 
the child has reached the age of ten months, and, if the mother's con- 
dition be such that she cannot furnish it, a wet-nurse should, if practi- 
cable, be employed. But after the age of six months additional 
nutriment is required. As a rule, the infant should be weaned at the 
age of twelve months, but longer nursing may be best under certain 
conditions, as the presence of hot weather, an abundant supply of good 
breast-milk, and, on the part of the infant, feeble digestion and easily 
deranged digestive organs. In case breast-milk cannot be obtained, 
cow's milk, properly diluted, according to the age, with water, or with 
a farinaceous solution is the best substitute. The reader is referred to 
the chapter relating to the diet of infancy, for full particulars relating 
to infant feeding. For infants with feeble digestion, it is better that 
the starch should be converted into glucose before its use, by Liebig's 
or a similar process. Four teaspoonfuls of barley, rice, or wheat flour, 
or of oatmeal, may be mixed with a pint of water, and boiled with con- 
stant stirring, five to ten minutes, when it is removed from the fire, 
and cooled to a blood heat. One teaspoonful of Trommer's malt for in- 
fants, Reid & Carnick's, or other good preparation of malt, should 
be added to this. This process thins the starch, and renders it more 
digestible. The gruel thus prepared should be mixed with cow's milk, 
in varying proportion according to the age of the infant. It is pro- 
bably best in the use of most of the farinaceous substances, and partic- 
ularly of barley, to grind in a coffee-mill the whole kernel, and make 



134 RACHITIS. 

the decoction from the husk, in or close to which the nitrogenous pro- 
ducts abound, as well as from the interior of the seed, in which the starch 
abounds (Jacobi), and from which the barley flour of the shops is pre- 
pared. The decoction should be strained through a sieve before adding 
the milk. The importance of obtaining cow's milk of the best quality 
for the rachitic, need not be dwelt upon in this connection. In hot 
weather in the cities, it is usually best to scald it as soon as received, 
and perhaps different times during the day, to prevent fermentation, for 
sour milk should never be used. 

Meat soups properly prepared according to the age, are useful addi- 
tions to the diet. I have elsewhere stated that in one of the institutions 
of New York, rachitis from being common was made to disappear almost 
entirely, by allowing a more generous diet, a part of which was the 
daily use of a little beef-tea. I have employed with apparently good 
results, beef-tea prepared as follows : Add half a pound of finely hashed 
beef to one pint of cold water, mix with it ten drops of dilute muriatic 
acid, allow it to stand cold with frequent stirring half an hour, then 
place it upon the table in a pail or large pan of boiling water, so as to 
heat it without coagulating the albumen. In an hour it is ready for use. 
The peptonized beef of the shops, as now prepared by Parke, Davis & 
Co., according to Ruclisch's method is also a most useful preparation. 

Medicines which improve the general health are all more or less bene- 
ficial in the treatment of rachitis, but lime and cod-liver oil are especially 
indicated. The following formula will be found useful in most cases : 

R. — Olei morrhua3 ....... f^i y - 

Aq. calcis, 

Syr. calcis lactophosphatis .... aaf^ij. — Misce. 

Of this, one teaspoonful should be given four or five times daily to 
an infant of one year. This combination agrees with the digestive 
function, and is readily taken by most infants. Cod-liver oil, while it 
improves the general nutrition, is especially useful in rachitis. 

Care should be taken to prevent deformities while the bones are soft 
and yielding. The patient should not be encouraged to stand or use 
the limbs until they become firmer. He should lie upon an even and 
soft mattress, and should be taken into the open air in a carriage. A 
uniform support of body and limbs is requisite in order to prevent 
curvature. 

In craniotabes the pillows should be soft, and care should be taken 
that the yielding parts of the cranium should not be unduly pressed 
upon. The perspirations may be relieved by sponging with vinegar 
and water. The infant should be regularly bathed in water a little 
cooler than the body, and rock salt may be added to the bath. The 
proper treatment of laryngismus stridulus, which so frequently com- 
plicates rachitis, is described in our remarks upon that disease. Con- 
stipation, common in the rachitic, should be treated by simple enemata, 
except so far as it can be relieved by change in the diet. When cur- 
vatures are unavoidable, orthopaedic treatment will subsequently be 
required. 

Such is an outline of the treatment which rachitis ordinarily requires, 



SCROFULA. 135 

but other medicinal agents may be found useful for their general tonic 
action, or by supplying lime-salts to the system ; among which may be 
mentioned, the compound syrup of the phosphates, the citrate of iron 
and quinia, wine of iron, the various preparations of cinchona, columbo, 
etc. Flieschmann recommends the fluorine compounds in order to in- 
crease and harden the enamel of the teeth, employing for the purpose 
the tooth pastille of Ehrhardt or Hunter, which contains the flouride of 
potassium. 



CHAPTEE II. 

SCKOFTJLA. 

The term scrofula (scrofa, a pig, from the resemblance of the enlarged 
cervical glands of a scrofulous individual to a swine's neck) is applied to 
a diathesis which is characterized by increased vulnerability of the tis- 
sues. The nutritive process of the tissues is readily disturbed even by 
trifling irritants or agencies in those who have this diathesis, and, 
therefore, the scrofulous are prone to inflammations of various parts. 
Inflammations, which can properly be considered as dependent upon this 
diathesis, or as occurring under its influence, are for the most part sub- 
acute or chronic, and they differ from ordinary inflammations in the 
fact of a greater cell-formation, and greater liability to cheesy degener- 
ation of inflammatory products, so that return to the healthy state by 
absorption is slow or impossible. Moreover, this diathesis, while it gives 
rise to certain inflammations, which do not occur or are rare in other 
states of the system, and which all physicians at once recognize as scrofu- 
lous, often modifies those common inflammations to which all persons, 
whether scrofulous or non-scrofulous, are liable, as coryza and bron- 
chitis, rendering them more protracted and less amenable to ordinary 
treatment. 

Scrofula is a disease chiefly of infancy and childhood. Manhood, 
especially the first years of it, is not entirely exempt, but scrofulous 
manifestations after the age of twenty years are feeble and infrequent, 
disappearing entirely as the individual advances towards middle life. 
The diathesis is most active prior to the age of ten years. 

Causes. — Scrofula is congenital or acquired. Parents who had scrofu- 
lous symptoms in early life, or who are in a state of decided cachexia, 
as from cancer, syphilis, intermittent fever, or tuberculosis, are apt to 
beget scrofulous children. Insufficient nourishment of the mother during 
a considerable part of her gestation, and advanced age, and therefore 
feebleness, of the father, are occasional causes. Near blood relationship 
of the parents is also a recognized cause, and to this has been attributed 
the scrofula of royal families. Children whose father and mother are 
first cousins are, according to my observations, likely to be scrofulous. 



13@ SCROFULA. ■ 

Again, those born with sound constitutions may acquire scrofula 
through antihygienic influences in the first years of life. Among the 
poor of New York we often observe one child in the family who presents 
scrofulous symptoms, while the rest of the children are well, and in 
many cases we are able to trace back the diathesis to some depressing 
cause or causes, which were sufficient to effect the peculiar change in 
the molecular condition of the tissues Avhich constitutes this disease. 
Obviously the causes of acquired scrofula are quite numerous. In the 
infant it is sometimes produced by insufficiency or poor quality of the 
breast-milk, or the use of artificial food during the period when breast- 
milk is required. Too protracted lactation also, especially if artificial 
food be almost wholly withheld, may cause it ; as may also, in those 
who have passed beyond the age of lactation, the continued use of a diet 
which is deficient in nutritive properties. 

Residence in damp, dark, and filthy apartments or streets may also 
produce it. Hence one reason of its frequent occurrence among the city 
poor. Residence in a small, crowded, and imperfectly ventilated apart- 
ment has been known to produce it, even with personal cleanliness, and 
a diet sufficiently nutritive. 

Scrofula may also be caused, in those previously robust and of sound 
constitution, by disease of an exhausting nature. The eruptive fevers, 
as smallpox, measles, and scarlet fever, if severe, occasionally produce 
this result ; or they render active the diathesis, which had hitherto been 
latent. In this city, where chronic entero-colitis of infancy is common, 
I have sometimes been able to trace the diathesis to the cachectic state 
and the impaired nutrition which it causes. 

There is probably no specific principle in scrofula, and therefore it is 
not infectious. In those exceptional instances in which scrofulous symp- 
toms appeared after vaccination in those previously healthy, it is prob- 
able that there were other more potent cooperating causes than vaccinia. 
That vaccination may communicate syphilis and erysipelas, has been 
shown by many observations. But while these diseases result from the 
reception into the system of certain poisons peculiar to them ; scrofula 
as certainly results from a variety of depressing agencies affecting the 
system in many distinct ways, with the general result of impairing its 
vigor and lowering its tone. It seems, therefore, unreasonable to suppose 
that these many and distinct agencies introduce a fixed specific principle 
into the system, which causes the phenomena of scrofula. If there be 
surroundings of a decidedly antihygienic character, or if there be an 
inherited predisposition from cachectic parents, the ordinary diseases of 
childhood, especially if severe and protracted, as scarlet fever, measles, 
pertussis, and even vaccinia (Henoch), may be sufficient to cause this con- 
stitutional anomaly. 

The primary scrofulous ailments, by which the diathesis is manifested, 
occur for the most part upon one of the free surfaces, namely, upon 
some part of the skin or mucous membrane. Certain standard authors 
attribute this to the fact that these parts are most exposed to the action 
of noxious agencies. The lymphatics lying in the inflamed area take 
up the altered lymph and carry it to the adjacent lymphatic glands, 
which become irritated, and undergo hyperplasia, and perhaps ulti- 



ANATOMICAL CHARACTERS. 137 

mately suppuration. This is, in a large proportion of cases, the begin- 
ning of scrofulous ailments. Nevertheless, in not a few instances, the 
first manifestations are in deep-seated and covered parts, as when scrofu- 
lous periostitis or osteitis occurs, without any peripheral lesion. 

Anatomical Characters. — There are no ascertained anatomical 
changes in the blood which are peculiar to scrofula. As long as the 
appetite and general health remain good, a*id the local affections have 
not occurred, the composition of this fluid is, so far as known, un- 
altered. In the cachexia which is present when the general health is 
impaired, the blood becomes impoverished, the red corpuscles lose a 
portion of their coloring matter, and the watery element predominates. 

The question arises whether the glandular hyperplasia of scrofula pro- 
duces an excess of white corpuscles in the blood. Virchow says: " Dur- 
ing the progress of an attack of scrofula, in which, if the disease run a 
somewhat unfavorable course, the glands are destroyed by ulceration, or 
cheesy thickening, calcification, etc., an increased introduction of cor- 
puscles into the blood can only take place as long as the irritated gland is 
still, in some degree, capable of performing its functions, or still con- 
tinues to exist ; as soon, however, as the glands are withered or destroyed, 
the formation of lymph-cells likewise ceases, and with it the leucocytosis. 
In all cases, on the other hand, in which a more acute form of disturbance 
prevails, connected with inflammatory tumefaction of the gland, an in- 
crease of the colorless corpuscles always takes place in the blood." (Cellul. 
Pathol.) Although the glandular hyperplasia occurring in scrofula 
increases the number of white corpuscles in the blood, scrofula cannot 
be regarded as sustaining any causative relation to that great and con- 
stant increase of white corpuscles which characterizes the disease leu- 
caemia ; for this disease, as remarked by Niemeyer, does not occur in 
childhood, when the scrofulous diathesis is active, but in manhood, when 
it has ceased to exist, or has become latent. 

Strumous inflammations of the cutaneous and mucous surfaces, which 
we have seen are the initial lesions in a large proportion of scrofulous 
cases, do not present any peculiar anatomical characters. Some of 
them are attended by an abundant formation of cells, and by dense in- 
filtration of the inflamed tissues ; but inflammations which do not 
depend on the strumous diathesis have the same anatomical elements. 
The most marked differences between the strumous and non-strumous 
inflammations are found in their origin, amount of cell-formation, and 
duration. 

The swelling of the lymphatic glands, which is so common in the 
neighborhood of scrofulous ailments, and which we have seen is in most 
instances the result of "conducted irritation," is due to hyperplasia of 
the lymph-cells with comparatively little or no increase of the stroma. 
Thus hyperplasia of the cervical glands is common, resulting from 
eczema of the scalp or face, or from otitis, or any of the forms of stom- 
atitis ; and so pharyngitis often gives rise to hyperplasia of the tonsils, 
which are lymphatic glands. The scrofulous nature of the glandular 
enlargement is apparent from the fact that it continues long after the 
primary inflammation which gave rise to it has abated. Lymphatic 
glands sometimes enlarge in those who are not scrofulous, either from 



138 SCROFULA. 

direct injury or propagated inflammation, but the tumefaction is com- 
monly less in degree, and in most instances it soon abates when the ex- 
citing cause is removed. 

The glands which most commonly undergo scrofulous enlargement 
are the cervical, inguinal, bronchial, and mesenteric ; but in those who 
are decidedly scrofulous, the glands in the vicinity of any protracted in- 
flammation are very prone .to hyperplasia. Thus I have seen enlarged 
and cheesy glands in the vicinity of scrofulous ostitis, or periostitis. 

Under favorable circumstances the glandular enlargement abates after 
a short time, by absorption of the redundant cells. But the products of 
hyperplastic or inflammatory action in the scrofulous individual are very 
liable to undergo cheesy degeneration, and the close causative relation 
of this cheesy substance with tubercles is now admitted. If resolution 
do not soon occur in the gland, it begins to undergo cheesy degeneration. 
It becomes firm and inelastic, its nutrient vessels narrowed and com- 
pressed, so that circulation through it ceases, and its cells, losing their 
liquid and vitality, shrivel away. This necrobiotic process appears in 
points in the gland, which enlarge and unite, till finally the whole gland 
becomes a dead mass, with shrivelled elements, of a whitish appearance, 
like cheese, the resemblance to which has suggested the name bv which 
the degeneration is known. 

In certain patients cheesy glands act as an irritant, like inorganic 
matter, producing suppurative inflammation, and their subsequent his- 
tory is that of an abscess. Purulent matter mixed with the cheesy 
debris escapes by ulceration upon the nearest surface, and scrofulous 
ulcers result, which slowly heal, leaving permanent cicatrices ; calcifica- 
tion of a cheesy gland occurs in exceptional instances. 

The cervical lymphatic glands in the scrofulous child, having under- 
gone hyperplasia of their cellular elements, not infrequently continue 
painless and indolent for a considerable time, producing, according to 
their size, an unsightly appearance, and without undergoing cheesy de- 
generation. Finally one or more become inflamed, and the broken- 
down gland substance softens and is expelled, mixed with pus, through 
an ulcerated opening in the skin. 

In order to complete the description of the anatomical character of 
scrofula, it would be necessary to describe the various inflammations to 
which the diathesis gives rise. Those which are most common and im- 
portant occur in the skin, mucous membrane, connective tissue, the 
joints, the bones with their periosteal covering, and the eye and ear; 
eczema and coryza are very common scrofulous ailments. Phlyctenular 
keratitis with great intolerance of light, otitis externa, causing pro- 
tracted otorrhcea, or media and interna, causing deep-seated pain, with 
impairment or loss of hearing, offensive purulent discharge, and, in the 
gravest cases, caries of the mastoid cells or caries extending along the 
petrous portion of the temporal bone even to the brain, causing men- 
ingitis and death, are not uncommon manifestations of scrofula, in the 
families of the city poor. Strumous cellulitis, occurring independently 
of the glandular affection, and quickly ending in suppuration, is also 
common. The term cold is applied to the abscess when the local symp- 
toms are slight, and there is but little heat of the parts. In young 



ANATOMICAL CHARACTERS. 139 

children the common seat of these abscesses is directly under the skin, 
so that if subcutaneous cellulitis running into an abscess occur in a 
young child, he probably has the strumous diathesis. 

The osseous system is very prone to inflammation in the scrofulous. 
Periostitis, ostitis, and arthritis, rare in those with healthy constitu- 
tions, are common in the scrofulous, in whom they result, even from 
very slight injuries, and sometimes without ,the recollection of any in- 
jury, and apparently from the direct influence of the diathesis. These 
inflammations are more common in the lower extremities than in the 
upper. Periostitis often occurs in scrofulous children without ostitis, 
when its usual seat is upon the shafts of the long bones, and it also 
accompanies inflammations of the bone, as pleurisy accompanies pneu- 
monia. The osseous inflammations of strumous patients are of two 
kinds: first, the destructive, producing caries with suppuration, or 
necrosis ; and, secondly, the so-called fungous, in which there is pro- 
liferation of tissue as in white swelling. Often both these processes co- 
exist, granulations and new tissue springing up, while the carious or 
necrotic process is extending. 

Dactylitis is in most instances, when occurring in young infants, a 
syphilitic affection, but in children of one year or more, in whom no 
marked syphilitic symptoms have previously occurred, it originates from 

Fig. 18. 




the strumous cachexia, as in the following case : Charles R., aged 
twenty months, was admitted into the New York Infant Asylum in 
1876. He had always been pallid, and had a strumous aspect. A 
physician acquainted with his parentage states positively that he is free 
from syphilitic taint, but when a few months old he had a mild form of 



140 ' SCROFULA. 

coryza, which gradually abated under anti-strumous treatment. At the 
age of five months he had purpura hemorrhagica of a severe form, but 
apparently not accompanied by hemorrhage from any of the mucous 
surfaces. The patches of extravasated blood were quite numerous and 
large over the trunk and limbs, and it was nearly three months before 
they entirely disappeared. A few months subsequently he began to 
have offensive otorrhcea on one side, which did not entirely cease. In 
December, 1876, at the age of eighteen months, well-marked dactylitis 
was first observed, involving the first phalanx of the left middle finger. 
The swelling was somewhat tender, and the skin which covered it had a 
slightly reddish or pinkish tinge, indicating the inflammatory nature of 
the malady. Neither joint at the extremity of the phalanx was involved, 
so that the movements were unimpaired. The dactylitis increased 
somewhat after it was first discovered, and then began to decline, under 
treatment with cod-liver oil and syrup of iodide of iron. The accom- 
panying woodcut represents the outlines, obtained by tracing the hand 
of the infant, when pressed on paper. 

Symptoms. — The scrofulous diathesis is exhibited by certain physical 
signs, which are present in infancy, but are more manifest in childhood. 
In one class of strumous children they are as follows : form, tall and 
slender; quickness of movement and perception; intelligence, good; 
skin, thin and semi-transparent, through which the superficial veins are 
distinctly seen ; features, delicate ; cheeks, habitually pallid or florid, 
and flushed by slight excitement; eyes, bright, with bluish conjunc- 
tiva ; muscles and bones, slender in proportion to their length. Those 
children who present these peculiarities are said to have the erethitic 
form of the diathesis. 

Others have what has been designated the torpid scrofulous habit, 
which is characterized by softness and flabbiness of the flesh, distended 
abdomen, large head, broad face, slow, languid movements, and an over- 
production of fat in the subcutaneous connective tissue in certain situa- 
tions, especially the nose and upper lip. Though typical cases can be 
readily referred to one or the other of these forms, there are many 
which are intermediate. 

One of the earliest of the scrofulous manifestations is subcutaneous 
cellulitis, alluded to above, giving rise to abscesses, commonly not large, 
with little surrounding induration, little pain, tenderness, and heat, and 
slow in discharging ; in a word, indolent. The most frequent seat of 
these abscesses is upon the extremities, but they may occur upon the 
scalp or elsewhere. They gradually heal when the pus escapes, their 
site being indicated for a considerable time by the depression and red- 
dish discoloration of the skin, which gradually returns to its normal 
state. Ordinarily, these abscesses do no harm apart from the reduction 
of the general health which they effect, but, when occurring in localities 
where the connective tissue lies upon the periosteum, as upon the 
fingers, periostitis may result, with destruction of the surface of the 
bone. Again, thrombi may occur in the vessels of the inflamed part, 
giving rise to emboli, embolismal pneumonia, and death. Specimens 
from such a case were presented by me to the New York Pathological 
Society in 1868. 



SYMPTOMS. 141 

The scrofulous affections of the skin often also occur at an early age, 
even before dentition. They are more frequent in infancy than in child- 
hood. The most common are eczema and impetigo, and, of rare occur- 
rence, ecthyma and lupus. But all these may occur in those who are 
not strumous or who do not present the characteristics of the strumous 
diathesis. 

Scrofulous affections of the mucous surfaces are scarcely less frequent 
than those of the skin. They present the ordinary features of mucous 
inflammations of a subacute and chronic character. 

Sometimes they occur without obvious exciting cause ; in other cases 
there is a cause of this kind, such as exposure to cold ; but the inflam- 
mation, once established, continues on account of the diathesis. It is 
often doubtful whether inflammations in strumous subjects be of such a 
character that it is proper to designate them strumous, especially if they 
occur upon such surfaces as are frequently the seat of ordinary inflam- 
mation. If the child have heretofore presented symptoms of scrofula, 
if the inflammation be subacute, and there be no apparent cause to 
originate or sustain it apart from the diathesis, it is probably of a 
strumous character. The diagnosis is rendered more certain by ob- 
serving the effect of anti-strumous remedies. The most frequent of 
these scrofulous inflammations of mucous surfaces are coryza, tracheo- 
bronchitis, and conjunctivitis. More rarely, stomatitis, pharyngitis, 
vaginitis, and, according to some, entero-colitis, are of a strumous 
character. Coryza gives rise to snuffling respiration, the formation of 
crusts around and within the nares, and excoriation .of the upper lip. 
The tracheo-bronchitis is attended by thickening of the mucous mem- 
brane, increased production of mucus and epithelial cells, and a loud 
tracheal rale, accompanying each inspiration. 

Strumous inflammation of the mucous membrane of the trachea and 
bronchial tubes is not a very infrequent disease in this city. It some- 
times originates in a simple inflammation from cold, or the tracheo- 
bronchitis of measles, or pertussis, and it is apt to continue, with its 
rales, cough, and scanty expectoration, for months, unless relieved by 
a proper course of treatment. 

Among the most common of the strumous affections, are inflammation 
of the eyelid, designated psorophthalmia, and that of the eye itself. 
The former is characterized by redness and thickening of the lids, 
detachment of the eyelashes, and inflammation and altered secretion of 
the "Meibomian glands;" the latter, namely, strumous ophthalmia, by 
pain, lachrymation, photophobia, and a moderate degree of hyperemia 
of the affected organ. One of the most common serious results of 
strumous inflammation affecting the eye, arises from the conjunctivitis 
and keratitis, namely, the formation of phlyctenule and ulcers on the 
margin of the conjunctiva and upon the cornea, fed by newly formed 
vessels. If not controlled by proper treatment, these may result in 
opacities more or less permanent, or possibly, worse still, in perforation, 
with its consequent ill-effects. 

Inflammations of the external and middle ear have their origin very 
generally in the strumous diathesis. Occasionally there is an exciting 
cause of the otitis, as an injury, or severe constitutional disease, like 



1-12 SCROFULA. 

scarlet fever. Protracted otitis, whether external or internal, and 
especially that form of it which leads to ulceration, destruction of the 
ossicles, and caries of the petrous portion of the temporal bone, it is 
proper, in a large proportion of cases, to regard and treat as strumous. 

The stubbornness and frequent disastrous consequences of scrofulous 
inflammation of the skeleton are well known. Nearly every bone, as 
well as its periosteum, is liable to this form of inflammation, but some 
are more frequently affected than others. Inflammation of the bone 
may terminate by resolution, by the formation of an abscess, or, and 
frequently, by carious or necrotic destruction of the bone itself. Ne- 
crosis is most apt to occur in the shafts of the long bones, caries in the 
spongy extremities of these bones, and in the spongy portions of the 
short bones. If abscesses form, the pus may finally escape from the 
system by a tedious ulcerative process, or, retained, may undergo cheesy 
degeneration. Scrofulous arthritis, if early detected and properly 
treated, may resolve, leaving no ill-effect; if otherwise, suppuration, 
ulceration, cartilaginous and osseous, and ankylosis, often occur. 

Scrofulous children are perhaps no more liable to inflammation of the 
internal organs than other children, but the inflammatory products are 
more liable to cheesy degeneration, and the prognosis is, therefore, less 
favorable. The most frequent of these inflammations, and the one of 
chief interest, is pneumonia. Catarrhal pneumonia, so frequent in 
early life, whether primary or secondary, in connection with measles, 
pertussis, etc., is a disease often involving grave consequences in those 
who are decidedly scrofulous ; since, instead of resolving, the affected 
lung-tissue presents a strong tendency to caseous degeneration ending 
in consumption of the lungs and death. I have most frequently noticed 
cheesy pneumonia during extensive epidemics of measles, as a compli- 
cation or sequel of this disease. It may occur in those who are not 
scrofulous, if the vital powers be greatly reduced, but it is so much 
more common in the scrofulous, that some recent writers have designated 
this form of inflammation by the term of scrofulous, instead of cheesy, 
pneumonia. From the fact, however, of its sometimes occurring in the 
non-scrofulous, the term cheesy or caseous, especially, too, as it expresses 
the anatomical state, seems more appropriate. 

The caseous substance which so frequently results from degeneration 
of the products of scrofulous inflammations, affords a nidus in which 
the tubercle bacillus frequently obtains lodgement, and conditions favor- 
able for its propagation. Hence the close etiological relations of scrofula 
or scrofulous inflammations to tuberculosis. 

Prognosis. — As scrofula may be acquired through antihygienic in- 
fluences, so it may disappear or become latent through influences of an 
opposite character. Therefore the manifestations of scrofula may be 
limited to a brief period, or they may occur at intervals through the 
whole of childhood, and the first years of youth. When the diathesis is 
inherited, and fostered by unfavorable circumstances, the scrofulous affec- 
tions appear earliest, are most varied and severe, and continue longest. 

In most cases, with proper treatment, the prognosis is good, but the 
danger to life depends on the nature and extent of the scrofulous in- 
flammation. The most common unfavorable result is the occurrence of 



T R BATMENT. 143 

pulmonary or general tuberculosis from the infection supplied by the 
cheesy substance, in the manner stated above. This is the usual result 
from cheesy pneumonia. The next most common cause of death, either 
directly or indirectly, is inflammation of the osseous system. Many 
deaths occur from inflammation of the vertebrae, or of the hip or knee- 
joint, when it has been allowed to continue a considerable time without 
proper treatment. Protracted suppurative inflammation of the bones is 
apt to produce amyloid degeneration of organs, which is permanent, and 
likely to prove fatal, or death may occur from exhaustion, with or with- 
out tuberculosis. Among the city poor meningitis is not very uncom- 
mon, consequent on long-continued otitis media and caries of the petrous 
portion of the temporal bone. Permanent impairment of sight and 
hearing often results from neglected strumous ophthalmia and otitis. 

At puberty the strumous affections gradually become less frequent, 
and they finally disappear in advancing age. Among the most robust 
adults are some who in early life presented indubitable symptoms of the 
strumous diathesis. 

Treatment. Prophylactic. — Measures designed to prevent scrofula 
are impossible without the cooperation of willing and intelligent parents. 
It is obvious that the prevention of congenital scrofula requires the 
treatment of disease or impaired health in the parent. If parents 
should be taught, or should remember, that good health in themselves 
is the necessary condition of the inheritance of a sound constitution in 
the child, and would adopt such therapeutic and regimenal measures 
as would procure this, the number of cases of inherited scrofula would 
be materially reduced. 

As the first years of life are very important, both for correcting the 
diathesis when inherited, and for preventing its development in those 
of sound constitution, care should be taken that the regimen of the 
child be such that it does not produce deterioration of the general 
health. The nursing infant, if the mother be in poor health, should be 
provided with a healthy wet-nurse, for in young children the diathesis 
may be acquired solely by the use of food that is scanty or of poor 
quality. Those old enough to be weaned should have plain and nutri- 
tious diet, with a proper admixture of animal food. More or less out- 
door exercise, and residence in a salubrious locality, with sufficient air 
and sunlight, are also requisite. 

Curative. — Since scrofula originates in a state of weakness existing in 
the parent in the congenital, and in the child in the acquired form of 
the disease, and is characterized by feeble resistance of the tissues to 
irritating agents, the inference is reasonable that all tonics have, to a 
certain extent, an anti-scrofulous effect upon the system. The ordinary 
vegetable tonics, and sometimes the ferruginous, are indeed useful in 
the treatment of scrofula. Employed in connection with proper regi- 
menal measures they are sufficient, in many cases, to remove the dia- 
thesis after a time, or render it latent. Besides these medicinal agents, 
which tend to correct the scrofulous diathesis by their general tonic 
effect, there are certain others which experience has shown to be bene- 
ficial in the treatment of scrofulous affections, and which are, therefore, 



li-i SCROFULA. 

largely used. One of these is cod-liver oil, which contains iodine among 
its many ingredients. 

Cod-liver oil is useless, or nearly so, in the torpid form of the dia- 
thesis, which is characterized by an increased deposit of fat in the sub- 
cutaneous connective tissue, slow circulation, and sluggish muscular 
movements. On the other hand, in the treatment of the erethitic form 
it possesses real value. Its protracted use in such cases does so modify 
the molecular condition of the tissues that they are less liable to inflam- 
mation, and the diathesis is, therefore, rendered milder or removed. 
From one to three teaspoonfuls, according to the age, should be given 
three times daily. While we frequently experience so much difficulty 
in administering it to adults affected with tuberculosis, and sometimes 
find it necessary to discontinue its use on account of its nauseating 
effect, scrofulous children rarely refuse to take it, and it does not seem 
to diminish their appetite. 

Iodine is justly celebrated as a remedy in the treatment of scrofulous 
maladies, but it is a question whether it has not been overrated as a 
remedy for the diathesis itself. Iodine employed internally is especially 
serviceable in glandular hyperplasia, and in scrofulous thickening and 
induration of the connective tissue and periosteum. In general, it 
should not be administered to children in its isolated state, on account 
of its irritating properties, but one of its compounds should be employed. 
The compounds which are chiefly prescribed in the treatment of scrofula 
are the iodides of starch, iron, potassium, and sodium. If, as is fre- 
quently the case, the patient be pallid, and his appetite poor, the iodide 
of iron should be preferred; if not in this cachectic state, the iodide of 
starch may be used. Pharmaceutists prepare syrups of both these 
iodides, so that they can be readily administered to the youngest child. 
The iodide of starch may be administered by dropping from one to five 
drops of the officinal tincture of iodine on a little powdered starch, and 
giving it in syrup. These iodides are preferable to the iodides of 
potassium and sodium for internal administration to children, as they 
are not irritating to the mucous membrane, and the iodine is readily set 
free. Prof. Dalton has, indeed, demonstrated that the iodide of starch 
is decomposed in most of the liquids of the body, and the iodine liberated. 

In New York City a large proportion of the scrofulous children are 
cachectic, and need iron, and the iodide of iron is more frequently em- 
ployed, and with good results, than any other iodine compound. The 
syrup of the iodide of iron, which is readily absorbed, should be given 
in one to two-drop doses three times daily to a child of six months, and 
one additional drop added for each additional year. Among the vaunted 
remedies of scrofula are phosphoric acid and the phosphate of lime. I 
have not employed these agents without at the same time using other 
remedies, and cannot say, therefore, to what extent they have been 
curative in my practice. Probably there is no better combination of 
remedies for the strumous diathesis than the following, which is now 
used in some of the institutions of New York, and which we have already 
recommended in the treatment of rachitis. 

R. — 01. morrhuse 2 parts. 

Syr. calcis lactophosphat 1 part. 

Aquse calcis 1 part. — Misce. 



TREATMENT. 145 

Dose, one teaspoonful to a dessertspoonful three or four times daily, to 
each dose of which, the syrup of the iodide of iron may be added. 

The internal use of mercury as an antidote for scrofula is now 
generally discarded. Unless, perhaps, in those cases in which the 
diathesis is immediately dependent on syphilis, its use for this purpose, 
from what we know of its therapeutic effects, would probably be more 
injurious than beneficial. Among the medicines which have from time 
to time been employed for the cure of scrofula, some of which have had 
considerable reputation but have nearly fallen into disuse, are walnut 
leaves, sarsaparilla, elecampane, conium, digitalis, horseradish, com- 
pounds of silver, gold, arsenic, baryta, and bromine. It is probable 
that none of these has any effect on scrofula or scrofulous ailments, 
except such as improve the appetite and general health, as horseradish. 

The same hygienic measures are required in the treatment of scrofula 
which are employed in the prophylaxis of it. The nursing infant should 
have healthy breast-milk, and if its mother belong to a tubercular or 
scrofulous family, or be feeble, a healthy wet-nurse should be employed, 
or it should be sent to the country, where suitable cow's milk as well as 
pure air can be obtained. The expressed juice of beef slightly boiled, 
the peptonized beef, or beef-tea prepared as recommended for rachitic 
infants, given several times daily in small quantity to infants, aids mate- 
rially in restoring a better nutrition of the tissues. Obviously, similar 
care is necessary in the selection and preparation of the food of children 
who have passed beyond the period of infancy. While the diet should be 
highly nutritious, it should be plain and easily digested, and given at 
sufficient intervals, so as not to overtax digestion. 

JFresh air, out-door exercise, daily bathing, personal and domiciliary 
cleanliness, are very necessary for the successful treatment of the dia- 
thesis. Since scrofula is comparatively infrequent in farming sections, 
scrofulous families are greatly benefited by farm life, with all the acces- 
sories to health which pertain to it. 

Tlie local scrofulous ailments require additional and special treatment. 
Those located on the cutaneous and mucous surfaces are less dangerous, 
as a rule, than the deeper seated inflammations ; still they should be 
promptly treated, not only for the inconvenience and annoyance which 
they cause, but because they are apt to lead to hyperplasia of the neigh- 
boring glands, which sometimes proves serious. Thus pharyngitis may 
cause a peripharyngeal adenitis and abscess, and a bronchitis may cause 
adenitis of the bronchial glands, with the probability of their cheesy 
degeneration. The so-called bronchial phthisis is believed to result, in 
a large proportion of cases, from a strumous bronchitis which has been 
allowed to run on uncontrolled by medicine, and a similar state of the 
mesenteric glands may result from intestinal catarrh. Inflammation of 
the skin or mucous surface occurring in the strumous, requires the con- 
tinued use of antistrumous remedies, conjoined with such treatment, 
designed to act locally, as is appropriate for the case. 

It is the common practice to treat the enlarged glands of struma by 
daily applications over them of the stronger iodine preparations. This 
treatment does not cause absorption of the redundant gland substance. 
It causes proliferation of the epidermic cells, and quickens the cell 

10 



146 SCROFULA. 

change in the gland underneath, so that leucocytes are liable to form in 
it. Cutaneous inflammation, as eczema or impetigo, causes hyperplasia 
of the lymphatic glands underneath. In like manner strong applications, 
which irritate the skin, are apt to quicken the cell formation, so that 
suppuration is a common result. I once produced accidentally such an 
amount of vesication over an enlarged, hard, and apparently indolent 
gland in an infant of fourteen months, that I was very anxious lest a 
sore would result, which would heal with difficulty, and yet instead of 
dispersion of the glandular swelling the pathological processes were so 
promoted that suppuration and discharge of pus occurred by the time 
that the cuticle had reformed. 

We know no better substance for the local treatment of strumous 
adenitis than iodine, and it should be applied, in my opinion, in such a 
manner that it is absorbed with the least possible irritation of the gland. 
The following will be found useful ointments and solutions for the treat- 
ment of these cases : 

R. — Potas. iodidi . . • ,^j- 

Ung. stramonii . . . . . . . . . ^j. 

To be rubbed over the gland several times daily. It should not be 
applied as a plaster, as it is too irritating and will vesicate. I have 
known a glandular swelling, which had continued about three months, 
to disappear in three weeks under its use in connection with internal 
remedies. Vaseline, in place of the stramonium ointment, makes a nicer 
preparation. Another useful iodine mixture for these cases is the 
following : 

R. — Liq. iodinii composita, 
Glycerinte, equal parts. 

To be applied as an inunction. Glycerine renders the skin soft and in 
a state favorable for absorption. 

In The Medical Press and Circular for August 3, 1870, J. Waring 
Curran states that he has used with great success what he designates a 
new iodine paint, consisting of half an ounce of iodine, the same quantity 
of iodide of ammonium, twenty ounces of rectified spirits, and four 
ounces of glycerine. 

Mercurial ointments have been recommended by writers of reputation 
for the treatment of these glands. I have employed them, and known 
them to be employed, but cannot say that I have ever observed any 
benefit whatever from their use. In the children's class at the Out-door 
Department at Bellevue we have discarded them entirely for this pur- 
pose, although both the citrine and white precipitate ointments, diluted 
with an equal quantity of lard, have been used with apparent benefit for 
chronic coryza of a strumous nature, and also occasionally for external 
otitis of the same nature. 

In a paper read at the meeting of the British Medical Association in 
1870, by Mr. Jordan, the writer recommends, as attended with success, 
vesication, not over the gland, but at a little distance from it, as, for 
example, behind the neck, for treatment of the cervical glands. But a 
mode of treatment which seems so unlikely to be beneficial requires 
stronger proof of its utility than has yet been presented. 



STRUMOUS DISEASE OF THE JOINTS 



147 



Fig. 19. 



A very important adjuvant to the external use of iodine over an 
inflamed gland is the constant application of cold. A small India-rub- 
ber bag containing ice, or muslin frequently wrung out of ice-water and 
applied over the gland, contracts the vessels, diminishes the activity of 
the morbid process going on underneath, and aids materially in the reso- 
lution. When the gland becomes so actively inflamed, or the inflamma- 
tion so advanced that redness of the skin occurs, applications of iodine 
are no longer proper. They increase the local disease. There is no 
longer any probability of resolution of the gland, and poultices should 
be applied. 

It is important that the diseases of the osseous system should receive 
early treatment, but, unfortunately, it is in reference to these inflamma- 
tions that error of diagnosis is frequently made. Thus I have known 
periostitis, with the diffused redness of the skin and heat which it pro- 
duces, to be mistaken for erysipelas, until the diagnosis was corrected 
from its persistence and non-extension. It is remarkable that strumous 
arthritis sometimes appears in two or more joints at once, as in the case 
related below. I have known it to occur nearly simultaneously in three 
joints, though only for a brief time in two of the joints, while it was 
chronic in the other. Hence, the fact that this inflammation is often 
mistaken for inflammatory rheumatism, and treated as such for some 
days, till its nature becomes apparent; and in like manner the febrile 
movement, lassitude, abdominal pain, etc., of 
vertebral caries are in a large proportion of cases 
attributed to something else, and the true dis- 
ease not suspected till irreparable damage has 
occurred, or much longer confinement and treat- 
ment required than would have been necessary 
with an earlier diagnosis. 

The common strumous inflammations of the 
osseous system which involve the joints, as Pott's 
disease, hip-disease, and white swelling, are 
usually quite amenable to treatment, early applied, 
which insures complete rest ; but, as a rule, cases 
neglected, or wrongly treated, go from bad to 
worse. There are exceptions, for a case may do 
well or terminate with moderate deformity with- 
out treatment, as in the following interesting in- 
stance, which also shows the difficulty which 
often attends diagnosis : 

Anna D., aged six years, came to the children's 
class in the Out-door Department at Bellevue in 
February, 1877, with the following history : Her 
health was good till two years ago, when she com- 
plained of pain of a mild form in both knees. 
Her parents attributed it to her rapid growth, 
and she was always able to walk with little suffer- 
ing. Slowly but steadily these joints began to swell. She has had no 
pain in other joints, and no member of the family has had rheumatism 
except a grandparent. She walks without complaint to the rooms of 




148 STRUMOUS OPHTHALMIA. 

the Bureau. The affected joints are about equally swollen, and it is 
evident on examination that they contain some serous effusion. Direct 
pressure is not painful, but pressing the bones together with a twisting 
or rotating movement gives some pain. She is pale, and has a stru- 
mous aspect. A sister of fifteen years has a similar swelling of one 
knee, which began at the age of seven or eight years, but which has 
received no regular treatment, has not prevented the free use of the 
limb, and has given her little inconvenience. 

The physicians who have examined this child, one of whom is an 
expert in orthopaedic surgery, agree that the disease is strumous and 
not rheumatic, and that it did not, during two years of neglect and un- 
restrained motion, go on to suppuration and destruction of the joints, 
was probably due to her good general health. 

Though the result in the above case was good, since there was little 
impairment in the use of the joints, and no suffering, yet delay and 
neglect in the treatment of those strumous inflammations which in- 
volve the joints are exceedingly dangerous, for if left to themselves 
they most frequently end in suppurative inflammation and ulceration, 
with all the sad consequences which these entail. Strumous inflamma- 
tions of the osseous system now receive more early and correct treat- 
ment than formerly, and orthopsedia, almost unknown till within the 
last twenty years, has become an important branch of surgery. For- 
merly in New York, especially in the tenement houses, we often met 
emaciated bed-ridden children with strumous osteitis and arthritis, their 
limbs swollen, and painful in motion, and offensive from the discharge, 
for the most part shunned by physicians, and with no prospect of relief 
except by amputation. Now this spectacle is comparatively infrequent. 
The early symptoms of these diseases being better understood and sooner 
recognized, the plaster of Paris or starch dressing to insure immobility, 
or ingeniously devised steel splints, which produce extension, and allow 
motion of the limb without friction of the inflamed surfaces, coming 
into general use, a large proportion of cases do not go beyond the first 
stage and are cured. 

Strumous Ophthalmia. 

(Written by Dr. 0. D. Pomeroy, Surgeon to the Manhattan Eye and Ear Hospital.) 

Strumous ophthalmia in young children, as described by the older 
writers, is simply a keratitis, or inflammation of the cornea, and is 
usually of the following varieties : phlyctenular or herpetic keratitis, 
and diffuse or parenchymatous keratitis. Perhaps it is a misnomer to 
designate these affections strumous. This general principle- governs 
most cases of these inflammations, to wit, depressed vital energy, which 
of course is the prominent characteristic of the strumous diathesis. 
As is well known, the cornea is a tissue of low vital power and any 
constitutional state, accompanied by depression, predisposes to an 
attack of keratitis. One of the commonest hospital experiences is to 
see a mild case of catarrhal conjunctivitis, which should be self-limiting, 
gradually extend to the cornea, causing an ulcerative keratitis. I be- 



PHLYCTENULAR KERATITIS. 149 

lieve all ophthalmic surgeons hold that the presence of corneal disease, 
not dependent on an obvious or specific cause, points to diminished 
vitality on the part of the patient. 

Herpetic or phlyctenular keratitis is the most frequent variety of 
corneal disease in children. It is a question whether it commences 
with a vesicle on the cornea, or a papule ; but in either case it soon 
becomes an ulcer. Ciliary injection probably precedes it, though this 
can by no means be always observed. In some patients the charac- 
teristic symptom, to wit, photophobia, may exist for a long time without 
injection of the eyeball, or any corneal changes whatever, but sooner or 
later it is probable that other characteristic signs of the disease will 
make their appearance. The photophobia is frequently accompanied 
by blepharospasm, making it well-nigh impossible to separate the eye- 
lids. When, however, this is accomplished, abundant tears gush forth, 
the child exhibiting signs of extreme distress. When the vesicle or 
papule is in a state of ulceration in the earlier stage, there may only be 
seen a minute loss of corneal tissue, without any opacity whatever. 
Soon, however, the ulcer becomes more or less opaque, perhaps seeming 
to be only a minute whitish spot on the cornea. This usually shows 
the commencement of reparative action. If the disease continue long 
a general conjunctivitis sets in, more especially of the ocular conjunctiva. 
Frequently there will be only one or not more than two or three ulcers, 
but, in exceptional cases, the cornea may have the periphery studded 
with phlyctenule, which, instead of promptly healing, proliferate so as 
to form elevated nodules, the so-called "scrofulous nodular bands." If 
the ulcer in any case continue long, a number of bloodvessels shoot out 
from the conjunctival border of the cornea, quite up to the ulcer, pro- 
ducing what may be termed a vascular keratitis. The discharge from 
the eye is often very acrid, causing catarrh of the lachrymal ducts, and 
even of the nares. Herpetic or eczematous eruptions on the cheeks, or 
the lip near the nostrils, are often seen, and may sometimes appear to 
be the cause of the disease rather than the eifect. In this condition the 
upper lip may swell considerably, giving the patient a very "strumous" 
look. 

The duration of phlyctenular keratitis is exceedingly variable ; two 
or three weeks may bring it to a close, or it may continue many months. 
The condition of the constitution probably determines its duration as 
much as any other factor. Of course, if an ulcer perforate the cornea 
staphyloma may result, rendering recovery more tedious and incom- 
plete. The diagnosis of this malady is not difficult. The photophobia 
so characteristic of keratitis, is present in no other disease except iritis, 
and the latter children rarely have; the little speck, spot, or abrasion 
on the cornea, together with the intolerance of light, is well-nigh diag- 
nostic. Photophobia is present in most forms of corneal disease, though 
not in all. The causes of phlyctenular keratitis are about as follows : 
Any condition of the system known as strumous, or whatever tends to 
lower the vital powers of the patient, affords a predisposing cause. I 
am impressed with the idea that exposure to cold or sudden change of 
temperature is the common exciting cause, barring any cutaneous dis- 
eases which may pass from the skin to the eye. Naturally any cause 



150 STRUMOUS OPHTHALMIA. 

which produces a conjunctivitis may also produce this disease second- 
arily. The process of dentition may have something to do with the eye 
disturbance, or any disorder of the intestinal canal; the latter, however, 
being rather predisposing than exciting causes. This disease also 
frequently occurs in patients affected with aural or nasal catarrh, but 
the condition of such children trenches closely on the state designated 
"strumous." 

The prognosis in a large number of cases is very favorable. The 
opacities of the cornea left after the healing of the ulcerations are the 
principal difficulties in the way of a good recoveiy. If the opacities are 
in the proper substance of the cornea, we are not certain that they will 
disappear by absorption, though they may. Nothing is more difficult 
than to determine this point. In the epithelial and Bowman's layers, 
as well as the posterior layer, opacities readily disappear. When the 
ulcer perforates the cornea we have an anterior synechia and the ap- 
pearance known as myocephalon, which usually disfigures the eye more 
or less for life. 

One discouraging point about these opacities is that, though they 
disappear, the cornea is left with a somewhat distorted curvature, causing 
irregular astigmatism, and if they chance to be near the centre of the 
cornea, great disturbance to vision results. I have often, in fitting 
spectacles, noticed that the patient's vision showed an unaccountable 
lowering, and on investigation have found a history of an infantile 
keratitis which had done all the mischief. In those cases described as 
having " scrofulous nodular bands," the proliferative nodules are very 
likely to undergo a variety of degenerations which do not end in a 
properly restored cornea. One great difficulty in making an exact 
statement here is the tendency of the keratitis to recur, and there is no 
knowing where the process will cease, after a number of recurrences. 

Treatment. — As the fifth nerve presides over the ciliary vaso-motory 
system of the corneal nutritive supply, it is obvious that treatment 
calculated to correct any of its morbid manifestations would be rational. 
Such is found to be the fact. Sulphate of atropia, in from one to two 
grain solutions, dropped into the eye three times daily, is probably 
superior to any other treatment. It inclines to break up the orbicular 
spasms, relieving the photophobia and ciliary neuralgia, diminishes vas- 
cularity, and contributes more to the relief of the patient than any other 
one remedy. If the pain be severe the atropine may be used six or 
eight times daily, or even it may be instilled every fifteen or twenty 
minutes, until pain is relieved. If an over-effect be reached the patient 
complains of dryness in the throat, possibly pain in the head, or he may 
have other cerebral disturbances, when the drops may be discontinued 
for a time. Muriate of pilocarpine in two grain solutions may be used 
in a similar manner and for the same purpose; but it contracts the pupil 
and renders the accommodation tense, the very opposite to the atropine 
effect. I have not much confidence in this remedy. Powdered calomel 
may be dusted into the eye every second day. A small quantity only 
should be used, since it is apt to collect in masses, which act as foreign 
bodies (we desire to produce irritation for a few minutes only). A 
drachm of table salt to a pint of water may be used to bathe the eyes 



TREATMENT. 151 

freely four or five times a day, used warm or cold according to the 
patient's pleasure, though -warm applications are more likely to be well 
received. Red precipitate ointment — 1^. Vaseline, 5j ; hyd. ox. rub. 
in very fine powder, gr. j to ij. M. — placed under the eyelids every 
day or two, is often very beneficial. Occasionally the ulcers show a 
disinclination to heal, when they may be touched with Arg. nit., gr. 
x, aquse dest., Sj. M. Wind a bit of absorbent cotton on a probe, dip 
this into the solution, and touch the ulcer, but no other point. Cupri 
sulph., in ten grain solutions, may be used for the same purpose. A 
protective bandage exerting moderate pressure on the eye sometimes 
does good, but it should not feel uncomfortable. If there be much 
spasm of the orbicularis, however, it is not indicated. If the pain in 
the eye continue, and the orbicularis be in a state of spasm, a cantho- 
lysis may be done — that is, divide the external canthus so as to cause 
the lid no longer to press hardly upon the eyeball, and close the wound 
thus made by stitching the skin to the conjunctiva above and below the 
incision, and placing one stitch in the extreme outer canthus. This ex- 
tends the length of the palpebral opening. The result of the operation 
is temporarily to break the power of the orbicularis, so as to arrest the 
spasm. This measure accomplishes in some cases what nothing else 
will. 

If the eye be painful, without spasm of the lid, and there be great 
photophobia, whether the eyeball be too hard or not, paracentesis may 
be done. The mode of performance is described in the treatment of 
ophthalmia neonati in another place in this book. After a while the 
accompanying conjunctivitis may need treatment in the ordinary way. 
Indeed, astringents may often be used quite early to obviate the irri- 
tating effects which occasionally result from the use of atropine. If an 
ulcer refuse to heal after the treatment already laid down, iridectomy 
may be done, though this is not often resorted to. Occasionally an 
ulcer may be cut across, by passing a narrow Graefe's knife through it, 
making a puncture on one side and a counter-puncture on the opposite 
side, and then cutting out quite through the ulcer, dividing it into two 
equal halves. All needful treatment for the constitutional condition of 
the patient should be attended to. So necessary are fresh air and sun- 
light that I would never shut the patient in a dark room. Blue or 
smoke-colored glasses may be worn to protect the eyes from a strong 
light, and in some cases the eyes may be protected by a bandage of 
some dark material, so that the patient may be taken for an airing with- 
out suffering. I would, however, advise to accustom the eyes to the 
light as much as possible without causing pain. 

In parenchymatous or diffuse keratitis we have quite a different 
array of symptoms. The margin of the cornea near the limbus may 
show a decided zone of injection of the conjunctival and episcleral 
vessels. It may be so excessive as to consist apparently of a rosy ring 
surrounding the cornea. These vessels after a time shoot inward, and 
may involve a large part, or even the whole of the cornea. In other 
cases, designated non-vascular diffuse keratitis, the injection is very 
slight indeed, and sometimes apparently wanting altogether. In either 
case, however, the same consequences result ; the cornea becomes dif- 



152 STRUMOUS OPHTHALMIA. 

fusely clouded, the process generally, but not always, commencing at 
the limbus. This cloudiness may be quite without lines or dots of 
opacity, like ground glass. Again it may appear composed of innumer- 
able minute opaque points or lines running in various directions. At 
first, the corneal epithelium escapes, presenting a regular and uniform 
polish, but afterward it becomes opaque. Again if the process involve 
the whole of the cornea, minute opaque spots may be seen in Descemet's 
membrane, giving it some of the characteristics of keratitis punctata. 
In the earlier stages there may be some pain and intolerance of light, 
but as a rule the disease, for a corneal affection, is comparatively pain- 
less. The duration of this disease is never short ; it may continue for 
many months, and it shows a strong tendency to relapse. The most 
frequent causes are hereditary syphilis and struma. Mr. Hutchinson, of 
London, always examines the teeth of these patients to see if there be 
anything characteristic of hereditary syphilis. As the same or similar 
teeth are often noticed in strongly strumous subjects, it becomes doubly 
interesting to make the observation. One point is apparent in most of 
these cases, that there are in almost every patient some signs of badly 
developed physique — that is, faulty tissue elaboration. As a rule, both 
eyes sooner or later become affected, pointing to a constitutional origin 
of the affection. 

In treatment we are often disappointed in our efforts. At the first, 
if there be pain or photophobia, atropine may be instilled, and the eyes 
bathed with warm or tepid water, several times a day. Tonics or 
alteratives are always indicated. One of the most useful prescriptions 
is the following: 

R . — Hydrarg. chlor. corros. . . . . . gr. j. 

Tine, cinchon. comp. 

Syr. aurantii aa ijiv. — Misce. 

Dose. — One teaspoonful three times daily after eating. 

Iodide of potassium is frequently given, and may very properly alter- 
nate with the mercurial ; children will bear very large doses of the 
iodide, and indeed they are often necessary if we would get the curative 
effects of the drug ; I would suggest from three to twenty grains three 
times daily, well diluted with water. Both these remedies may be con- 
tinued for months, but ptyalism should always be avoided. Cod-liver oil 
with extract of malt may be administered. Whatever tends to im- 
prove the patient's general condition is indicated. Exercise in the 
fresh air is good, but the pernicious effects of cold must be avoided. 
Paracentesis of the cornea rarely does good, but occasionally iridectomy 
may be of benefit. The complication of iritis or irido-choroiditis is not 
common, though it does occur. When the disease becomes very chronic 
there will be hardly vascularity enough for the purposes of repair. This 
being the case, stimulating collyria may be used, similar to what is indi- 
cated in conjunctivitis. Olive oil and spirits of turpentine, in equal 
parts, may be applied to the eye every second day. Bathing with warm 
water, sufficiently to congest the eye, will sometimes be serviceable. An 
attack of acute conjunctivitis has been known to do good. But do what 
we may, this affection sometimes runs on unchecked for a very long 



TUBERCULOSIS. 153 

time. From some recent experiences I am inclined to believe that bi- 
chloride of mercury internally and atropine as a collyrium, are of as 
much value as any other agents in the treatment of this obstinate 
malady. 



CHAPTEE III. 

TUBEKCULOSIS. 

The term tuberculosis is applied to a disease which is characterized 
by the formation of small tubercles or nodules in one or more organs. 
Though more prevalent in some countries or localities than in others, it 
occurs in all or nearly all parts of the globe, from which we have exact 
information, and it has been more destructive to human life than any 
other one disease. 

Etiology. — The most brilliant discovery of the last decade relating 
to the etiology of diseases, is that of the specific principle of tubercu- 
losis. It has long been suspected by observing physicians that a specific 
cause did exist, and that this disease is to a certain extent infectious, 
but it is only recently that patient microscopic investigations have 
triumphed over the difficulties which surround this subject, and have 
detected the microorganism which has been so fatal to the human race. 
The honor of discovery belongs mainly to Dr. Koch, of Berlin. In his 
investigations Koch invariably found a certain bacillus in all recent 
tubercles, proving beyond a doubt that they always accompany the 
development of the tubercular nodule. By inoculating guinea-pigs, 
rabbits, and cats with tubercular material he communicated tuberculosis, 
reproducing the tubercular nodule, in which he always found the same 
bacillus. But it still remained to determine the relation of the bacillus 
to the tubercle, whether it was merely an accidental accompaniment, or 
whether it sustained a causative relation, producing the nodule by its 
irritating action on the cellular elements of the part where it happened 
to lodge. After many trials, Koch succeeded in preparing a pabulum 
in which the bacilli grew and reproduced their kind. By adding a 
little of the first cultivation to the pabulum, he produced a second 
cultivation, and after a series of cultivations he produced a bacillus 
which was evidently freed from all other substances. With the bacillus 
of the last cultivation he was able to produce the tubercular nodule, 
having all the characteristics which are observed when it is developed 
in the usual way in man. Different microorganisms take coloration 
differently, and Koch was enabled to discriminate the tubercular bacillus 
under all circumstances from other microbes by the peculiar color im- 
parted to it. 

The tubercle bacilli have the form of " delicate rods, from a quarter 
to half the diameter of a blood corpuscle in length." The more severe 



154 TUBERCULOSIS. 

the tuberculosis, the greater the number of bacilli. They occur not 
only in the recent tubercle, but also in immense numbers in the peri- 
phery of the caseous masses of a tubercular patient. They are found 
not only elsewhere, but also in the interior of the giant cells, as many 
as twenty even in some cells. They do not seem to have the power of 
movement, and oval spores are found in some of them. They grow in 
a temperature of 86° F. to 104° F., and not in a temperature outside 
these limits. 

As might be expected, these microscopical researches of Koch have 
attracted wide attention, and have led to a repetition of his experiments 
by many pathologists, and to new experiments relating to the etiology 
of tuberculosis. The result has been to establish more firmly the views 
of Koch, and the doctrine that tuberculosis is a specific disease, and that 
the bacillus is the specific principle, appears to be fully established. 

Among the most thorough and convincing researches bearing on the 
causative relation of microorganisms to tuberculosis, growing out of 
Koch's discovery, were those contained in a report to the London Asso- 
ciation for the Advancement of Medicine by Research (Practitioner, 
London Lancet, March 17, 1883). Experiments were made with the 
cultivated bacilli obtained from Koch. "Twelve animals were inocu- 
lated with these organisms, chiefly into the anterior chamber of the eye, 
and all of them became tuberculous, and that more rapidly than after 
inoculation of tuberculous material. The tubercles produced in these 
cases were infective, and caused tuberculosis in other animals. On 
examination of tuberculous material, Koch's tubercle bacilli are always 
found, though in varying numbers. . . . About eighty organs of 
tuberculous animals and thirty- six cases of human tuberculosis were 
examined, and in all of these, without exception, tubercle bacilli were 
found. 

The discovery of Koch has already proved of great importance as an 
aid in diagnosis, for the sputum of tubercular patients contains the 
bacillus. Tubercular sputum affords a soil in which the bacillus thrives 
and multiplies, as it does in the tissues of a tubercular patient, and by 
careful microscopic examination we are able to discover it in this 
sputum, while it is absent from non-tubercular sputum. According to 
Frisch (Wiener med. Woch., No. 46, 1883), the bacilli were found 
without an exception in the sputum of 140 patients with confirmed 
tuberculosis, while the sputum of 150 non-tubercular patients was in 
every instance free from them. Heitler ( Wiener med. Woch., No. 43, 
1883) examined the sputum of 140 tubercular patients, one of whom 
had miliary tubercles, and one other caseous pneumonia. All the other 
cases were chronic and were grouped by the author as follows : 1st. Six 
cases of old infiltration of the apices of the lungs, cured with the per- 
sistence of dulness on percussion, without rales. No bacilli observed. 
2d. Twelve cases of tuberculosis with slight dulness and dry rales. 
In two of these, notwithstanding marked physical signs, fever was 
absent, and the tubercular process was arrested apparently ; no bacilli. 
In the sputum of the remaining ten cases, bacilli were present in all 
the examinations except two. The third group contained cases of 
advanced and progressive tuberculosis, and the fourth group cases of 



ANATOMICAL CHARACTERS. 155 

advanced chronic phthisis but with remissions. In the sputum of these 
two groups, bacilli were always observed. That Heitler, in six in- 
stances, witnessed the disappearance of bacilli when the tubercular 
process was arrested, is an interesting fact, as showing the relation 
of the bacilli to tuberculosis. He examined the sputum of twenty-nine 
non-tubercular patients, patients with pneumonia, bronchitis, bronchial 
dilatation, and putrid bronchitis with gangrene, and in no instance 
found the bacilli of tuberculosis. 

As usually happens when a great discovery is announced, there are 
dissentients; there are those apparently competent to express an 
opinion, as Spina and Formad, who do not accept, or only partly 
accept the views of Koch. But the testimony of many observers, con- 
stantly accumulating, tends to establish more securely the doctrine of 
the parasitic origin of tuberculosis, and it is now apparently as securely 
established as most doctrines in pathology. 

Koch's discovery necessitated revision of the teachings long accepted, 
relating to tuberculosis. The tubercular nodule is, as we will see, an ag- 
gregation of cells, produced from the cellular elements of the part where 
the nodule appears through a proliferating process, caused by an irri- 
tant, and in the light of our present knowledge we consider the bacillus 
to be the irritant. A local corpusculation, and a cellular nodule may 
be produced in the lungs or elsewhere by the lodgement of a non-specific 
irritant, whether organic or inorganic, as putrid cheese, particles of 
dust, or metallic particles, and thus far no cells have been discovered 
in nodules thus produced, which are characteristic of tuberculosis. The 
giant cells which at one time were thought to be peculiar to the tuber- 
cular nodule, have been found in growths of another nature, as in gum- 
mata. The characteristic and peculiar element in the tubercular nodule 
is the bacillus. 

It has long been the belief from clinical observations, in Southern 
Europe, and of certain observing physicians in the temperate regions of 
Europe and America that phthisis is contagious, and the acceptance of 
the parasitic theory will probably soon render this belief an established 
principle in pathology. Already many instances have been published 
in the journals which appear to show the infectiousness of tuberculosis, 
as the following : In an inland town in Europe, a midwife with advanced 
phthisis, had been in the habit of blowing into the mouths of new- 
born infants, and so many of them perished of tubercular disease, as to 
excite attention and cause alarm, while those attended by a healthy mid- 
wife remained well. Dr. E. I. Kempf relates the following striking 
example in the Louisville Medical Neivs for March 22, 1884 : In the 
fall of 1880, a girl of eighteen years, whose brother had died of con- 
sumption, was found to have tubercles at the apices of both lungs. She 
slept in the general dormitory with the other sisters, and in four months 
nine of her companions began to cough, and were found to have tuber- 
cles. No one of the sisterhood had previously had disease of this kind. 
The fact that wives devoted in their attendance on consumptive husbands, 
frequently perished of the same disease, physicians in various countries 
have long remarked, but it has usually been attributed to the depressed 
state of system incident to long watching and grief, and not to any 



156 TUBERCULOSIS. 

contagious property. But now that a clearer insight has been obtained 
into the nature of tuberculosis, and both microscopical researches and 
clinical facts indicate its communicability, more caution will be exercised 
in the intercourse with patients. 

The causative relation of scrofula to tuberculosis we have considered 
elsewhere, but we may here repeat that scrofulous ailments, especially 
the caseous products, afford the soil which is favorable to the growth 
and multiplication of the bacilli. Hence these microbes are not infre- 
quently found in scrofulous products, showing that the tubercular has 
supervened on the scrofulous disease. Kanzler treats of the relation of 
scrofula to tuberculosis, in the Berlin, Jclin. Woeh., January 14, 1884. 
He believes that the two diseases are distinct, but that, as expressed by 
the French reviewer, la scrofule off re un terrain de predilection pour 
le developpement de la tuberculose. He has discovered bacilli only in 
a minority of the local manifestations of scrofula, never in glands which 
had not undergone suppuration or caseation, never in eczema, impetigo, 
suppurative otitis media, and never in the nasal, conjunctival, pharyngeal, 
and vaginal catarrhs of the scrofulous. It is not till degenerative changes 
have occurred in the inflammatory products of scrofula, that the bacilli 
of tuberculosis appear, indicating the supervention of the latter disease. 

Anatomical Characters of the Tubercle. — As Virchow pointed 
out, the tubercular nodule when recent, is semi-translucent and small, 
attaining about the size of a millet seed, and consisting mainly of cells. 
The cells which he considers characteristic of tubercle, and of which it 
is chiefly composed, resemble the white corpuscles of the blood in appear- 
ance and size, but some are smaller, and others larger than those cor- 
puscles. They have been designated the lymphoid cells. Each cell 
when fully developed, has a bright homogeneous nucleus, small and 
spherical, or large and oval, and nucleoli. A large cell sometimes con- 
tains two or more nuclei. The lymphoid cells appear to be developed 
from the cellular element of the connective tissue. This is Virchow 's 
belief. In addition to these cells, which constitute the greater part of 
the tubercle, large uninuclear cells are also observed, designated epithe- 
lioid cells. They resemble large and swollen endothelial or epithelial 
cells, and they are believed by pathologists to be produced from these 
cells, which lie within the area of the nodule. A third cell also occurs, 
known as the giant cell, from its size. It has many nuclei, and oc- 
cupies chiefly the central part of the nodule. All these cells, as has 
been recently shown, occur in other pathological products, besides the 
tubercular nodule, and no one of them is therefore characteristic of it. 
But the element which is of greatest importance, since it sustains a cau- 
sative relation to the disease, was, as we have seen, the last discovered. 
The bacillus is always found in the recent tubercle lying without the 
cells, as we have stated, but also in the interior of the giant cells, for 
which it appears to have an affinity. A fibrous network with more or 
fewer bloodvessels, surrounds the cells and holds them together. The 
bloodvessels belong to the normal tissues and are not a new growth, the 
tubercle having developed around them. The tubercles are single, cr in 
clusters, forming masses of considerable size. 

When the tubercle has attained a certain age, caseation always occurs 



ANATOMICAL CHARACTERS. 157 

in its centre and extends outward, causing an opaque and yellowish- 
white dead mass, in which fragmentary cells can be observed under the 
microscope. Caseation is now known to be a form of decay which is 
common to pathological products of different kinds, and is not peculiar 
to tuberculosis, as was supposed before the time of Virchow. It occurs 
in consequence of abundant exudation or cell formation, and the com- 
pression and obliteration of vessels. It is, therefore, more common in 
scrofula than in any other disease, since scrofulous inflammations afford 
the conditions in which it is especially apt to occur. The yellow 
tubercle is, therefore, only an advanced stage of the semi-transparent or 
miliary tubercle. In the cheesy metamorphosis granules of fat are 
deposited within and around the cells, and the cells shrivel and disinte- 
grate. These shrunken granular and fragmentary cells were believed 
to be the true tubercular cells until Virchow pointed out their true 
character. When the tubercle or the tubercular mass becomes yellow or 
caseous, and circulation ceases in it, it is surrounded by a vascular zone 
in which circulation still continues. It is very seldom, perhaps never, 
absorbed, although particles of it may enter the lymphatics or blood- 
vessels, and be carried elsewhere with the bacilli. It is an irritant, 
producing inflammation in the surrounding tissues, with thickening, 
induration, and abundant production of pus cells, which mingle with the 
elements of the tubercle. Its history henceforth is that of an abscess, 
and ulceration and discharge of the liquefied substance upon one of the 
free surfaces is the common result. In rare instances the tubercle, 
instead of cheesy degeneration, undergoes fibroid degeneration or crete- 
faction. 

Various pathological conditions furnish the soil in which the bacillus 
obtains lodgement and grows, and in this way becomes a cause of tuber- 
culosis. Cheesy pneumonia is not an infrequent cause of tuberculosis, 
and so are exhausting suppurations. During epidemics of measles 
many cases occur of cheesy pneumonia ending in tuberculosis. Cheesy 
and disintegrating lymphatic glands, as the bronchial, often also lead to 
tuberculosis. 

Anatomical Characters in Infancy and Childhood. — The ana- 
tomical characters of tuberculosis in the first years of life vary in certain 
particulars from the form which they present in the adult, but after the 
age of three years the differences are fewer and less pronounced than 
previously. 

Tubercular laryngitis, so common in the adult, is absent in a large 
proportion of cases under the age of three years, and when present it 
has little intensity. Ulceration of the larynx very seldom occurs. This 
has been attributed to the fact that there is so little expectoration in 
young children, the sputum being an irritant. Niemeyer, however, does 
not consider the sputum of tuberculosis sufficiently irritating to cause 
laryngitis and laryngeal ulceration ; but the arguments in favor of this 
mode of causation, in my opinion, more than counterbalance those which 
have been presented against it. 

I have never met a case of tubercular ulceration of the larynx or 
trachea in the post-mortem examination of young children, nor do I 
recollect ever treating a case in which there was that degree of dysphonia 



158 TUBERCULOSIS. 

which indicated ulceration. Rilliet and Barthez, in more than 300 
necropsies of tubercular cases, found no ulcers in the larynx or trachea 
under the age of three years ; but met 8 cases between the ages of three 
and ten years, and 8 between ten and fourteen years. The ulcers, 
whether seated in the larynx or in the trachea — and they are in most 
cases in the former, since the inequalities upon the surface of the larynx 
favor the retention of the sputum — are commonly small, superficial, 
round or elongated, and with little thickening or infiltration of their 
borders. Occurring in the folds of the mucous membrane, as, for ex- 
ample, around the vocal cords, their form is usually elongated. 

Bronchitis is not infrequent. This inflammation is due to, and de- 
pendent on, the pulmonary tubercles, and is therefore most intense in 
the part of the lung where the tubercles are most abundant and furthest 
advanced. Consequently it is more intense on one side than on the 
other, and it may be unilateral. It differs in this respect from idio- 
pathic bronchitis, which is commonly pretty uniform on the two sides. 
It differs also in the fact that it is sometimes accompanied by ulcerations. 
The ulcers are round or elongated in the direction of the axes of the 
tubes, and, like those of the larynx or trachea, are superficial. Idiopathic 
bronchitis of infancy and childhood does not cause ulceration. Circum- 
scribed inflammation may attack a bronchial tube, as, indeed, the 
trachea, and give rise to ulceration and perforation, from the presence 
and pressure of a diseased lymphatic gland external to the tube. This 
subject will be treated of hereafter. 

Lungs. — It is well known that in the adult, tubercles are always 
present in the lungs, if they occur in any part of the system. I have 
met two cases in which the lungs were free from tubercles in 36 post- 
mortem examinations of children who died of tuberculosis. One of the 
two was an infant, but its exact age is not stated in the records. It had 
cheesy degeneration of the thymus and bronchial glands, enlargement of 
the mesenteric glands, but without cheesy degeneration, and disseminated 
tubercles in liver and spleen. The other, fifteen months old at death, 
had tubercular meningitis, with numerous granulations upon the con- 
vexity of the brain, and the other usual lesions of meningeal inflamma- 
tion, with bronchial and mesenteric glands slightly enlarged and cheesy, 
and one of the former softened. In one case, then, in 18, the lungs 
had escaped the disease. Rilliet and Barthez state that they found the 
lungs non-tubercular in 47 cases in 312, and Hiller did in 25 cases in 
160. In their cases, therefore, the lungs were exempt from tubercles in 
about 1 case in 7. But it is to be recollected that the statistics of these 
observers were prepared at the time when all cheesy degenerations were 
thought to be tubercular, and the bronchial and mesenteric glands are 
sometimes cheesy when there are no tubercles or lesions referable to 
tuberculosis in any other part of the system. I have records of two 
such cases, which I reject from my statistics of tuberculosis, as there is 
no evidence that the disease was anything else than cheesy inflamma- 
tion. Did I include these cases, my statistics would more closely 
correspond with theirs. 

Pulmonary tubercles in children under the age of three years are, as 
a rule, discrete, and disseminated through the lungs. In cases at this 



LUNGS. 159 

age, which have advanced to a fatal termination, we find yellow tubercles 
from the size of a pin's head to that of a shot in the different lobes ; 
many still semi-transparent if the disease have been of short duration, 
but if protracted most of them yellow, and here and there one softened 
and surrounded by condensed fibrous tissue. Around the semi-trans- 
parent or gray tubercles, many of which were growing, and therefore 
were in the state of active cell proliferation at the time of death, 
narrow vascular zones can often be detected by the naked eye. 

Under the age of three years, tuberculosis exhibits but little tendency, 
perhaps none, to affect the upper lobes sooner or in greater degree than 
the lower. 

The following are the statistics relating to the site of the tubercles in 
the lungs in the cases which I have examined. All, it is to be remem- 
bered, were under the age of three years : 



Tubercles disseminated throughout the lungs . . . .26 

Tubercles disseminated throughout the two upper lobes . . 3 
Tubercles disseminated through right middle lobe and left lower 

lobe only ........... 1 

Tubercles disseminated through left upper lobe only ... 2 
Tubercles disseminated (few and semi-transparent) in left lung 

only 1 

Tubercles disseminated in three points in right, and two in left 

lung ............ 1 

No tubercles in lungs 2 

~36 

Between the ages of three and fifteen years, statistics show that the 
upper lobes are more liable to tubercles than the lower ; but the differ- 
ence in liability is not great. In many cases occurring in this period, 
the different lobes are affected nearly simultaneously, and not very in- 
frequently the upper lobe is the last which is involved. In October, 
1866, I made the post-mortem examination of a boy who died in the 
Children's Service of Charity Hospital, at the age of fifteen years, and 
small scattered tubercles were found in the lower lobe of the left lung, 
while all other portions of these organs were healthy. Rilliet and 
Barthez, who include in the same statistics all cases from birth to the 
age of fifteen years, found gray semi-transparent tubercles 



In the right superior lobe in . . . . . . . .63 

In the right middle lobe in 43 

In the right lower lobe in . . . . . .55 

In tbe left superior lobe in ........ 65 

In the left inferior lobe in ........ 54 

The same observers found yellow tubercles in the 

Eight superior lobe in ......... 40 

Eight middle lobe in 28 

Eight inferior lobe in . . . . . . . . .39 

Left superior lobe in ......... 35 

Left inferior lobe in . . . ... . . .31 

Tubercle, especially when softening commences, is itself an irritant, 
exciting inflammation around it. Inflammation occurring from this cause 



ICO TUBERCULOSIS. 

is obviously likely to be protracted, continuing for weeks or months, 
unless the tubercular matter be eliminated by ulceration. The highly 
vascular and delicate lungs of the young child are very liable to inflam- 
mation when they are the seat of tubercles, and as the tubercles are 
disseminated, the pneumonia is commonly more extensive than when it 
occurs from ordinary causes. In fifteen, or nearly one-half of my cases, 
there was pneumonia affecting portions of one or more lobes, or an entire 
lobe. From the extent and position of the solidified portions, it was 
obvious that in most instances the inflammation originated from the 
irritating effect of the tubercular matter, while in others it was due to 
hypostatic congestion, occurring in consequence of the long-continued 
recumbent position and feebleness of circulation. In these fifteen cases 
the seat and extent of the inflammation were as follows : 



Nearly entire right lung 2 

Nearly entire middle and lower lobe ...... 1 

Entire left upper lobe 2 

A considerable part of both lungs 1 

Posterior parts of both lower lobes . . . . . • . .4 

Posterior part of left lung . . . . . . . .1 

Left lower lobe, and right middle and lower lobes .... 1 

Left upper lobe (contained a large cavity) and posterior part of left 
lower lobe ........... 1 

Nodules of inflamed lung around tubercles . . . . .2 

The inflammation in about one-third of the cases was due to hypo- 
stasis, since it occurred in depending portions, extended but little into the 
lungs, and sustained no relation to the amount of tubercle. It was in 
the stage of red or, more rarely, of gray hepatization. 

In seven of the cases there were pulmonary cavities as large in pro- 
portion as we ordinarily find in tuberculosis of the adult. The seat of 
one was in the right lower lobe ; of two, the left upper lobe ; of one, 
the right upper lobe; of another, the right lung, its exact seat not stated; 
and in the remaining case the cavity, which was the largest of all, occu- 
pied the interior of all three lobes on the right side. Some, idea of the 
size of these cavities may be learned by the following extracts from the 
records: 1st Case. "A small superficial cavity communicating on one 
side with a bronchial tube, and on the other side with a small circum- 
scribed collection of pus in the pleural cavity." <2d Case. "Cavity of 
the size of a hickory-nut." 3d Case. "Cavity of the size of a large 
hickory-nut." 4th Case. "Cavity three-fourths of an inch in diameter." 
5th Case. "A large abscess." 6th Case. "The cavity occupied nearly 
the whole of the interior of the left upper lobe." 7th Case. "About 
half the right lung excavated into a cavity which extended through the 
three lobes." 

Circumscribed pleuritis, produced by tubercles underneath the pleura, 
was observed in seven cases. It was ordinarily attended by little exuda- 
tion except the fibrin, but in one case a sufficient amount of serum had 
been exuded to compress considerably the lung. Pus was not observed 
in any notable quantity. 

Emphysema was present in several cases, chiefly in the upper lobes, 
sometimes vesicular, with fulness or bulging of the lung, an anasmic 



LUNGS, 161 

appearance of it, and doughy, inelastic feel. In other cases emphysema 
was interstitial, producing little bladders of air under the pleura, espe- 
cially toward the root of the lung, or separating the lobules by wedge- 
shaped or irregular interspaces filled with air. In one case air had 
escaped from an emphysematous bladder into the right pleural cavity, 
causing pneumothorax and collapse of the lung. 

Next to the lungs, the bronchial glands are more frequently diseased 
than any other organs, in the tuberculosis of infancy and childhood. 1 
They undergo the successive structural changes which characterize 
glandular inflammations, namely, hyperplasia, and more or fewer of them 
cheesy degeneration and softening. In the state of hyperplasia their 
firmness is diminished, and thej have a pale flesh-color. Cheesy degen- 
eration commences in one or more points in the gland, sometimes in 
the peripheral, sometimes in the central portion, and it extends till the 
whole gland presents the well-known cheesy appearance. When the 
gland softens, the thick liquid has a puriform appearance, consisting 
of amorphous matter, fatty particles, and the shrivelled and disin- 
tegrated cells of the gland. Soon pus-cells occur, and their number 
increases. 

Rilliet and Barthez state that the bronchial glands were tubercular 
in 249 cases in children, while the lungs were tubercular in 265. All 
cheesy glands, it is to be recollected, they considered tubercular. In 4 
of the 36 cases which I have examined, no record was preserved of the 
state of the bronchial glands; in one case there was no perceptible 
hyperplasia and no cheesy degeneration; in two there was hyperplasia, 
but no cheesy degeneration, while in the remaining twenty-nine cases 
there was cheesy degeneration of more or fewer of the enlarged glands, 
or parts of them, with occasional softening. In the fact that the 
bronchial glands are enlarged and caseous, we have an explanation in 
part of the fact, that the symptoms in the tuberculosis of young children 
differ from those in the adult, since Louis found the bronchial glands 
involved in only twent}^-eight per cent, of the adult cases of tuberculosis 
which he examined, and Lombard in only nine per cent. A gland 
pressing upon the recurrent laryngeal or pneumogastric nerve, or the 
trachea, may give rise to dyspnoea and a cough ; or on the descending 
vena cava or one of the vense innominatee, to congestion of the brain 
and meninges, intracranial serous effusion, and even thrombosis in the 
cranial sinuses. That a softened bronchial gland is not infrequently 
eliminated from the system, by ulceration, into a bronchial tube or into 
the trachea, is well known. In one case which I observed the ulcer- 
ation had destroyed portions of three of the cartilaginous rings of a 

1 The term bronchial phthisis has long been applied to that state in which 
the bronchial glands are enlarged and cheesy. Now this glandular disease, we 
have seen, is often the result of inflammation in the strumous; and while it may be 
the cause of tubercular infection, is probably not, in most instances, tubercular 
itself. But microscopy has not yet drawn i,he distinction between the cells of 
lymphatic glands, which cause the enlargement by proliferation when the glands 
are inflamed, and the cells of the tubercular neoplasm. They appear alike in the 
field of the microscope. Therefore it seems proper not to attempt to distinguish 
scrofulous glands from tubercular, when they occur in a patient affected by 
tuberculosis. 

11 



162 



TUBERCULOSIS. 



bronchus, and the aperture was plugged by a cheesy fragment of a 
softened gland which protruded. Occasionally, it is stated by authors, 
the ulceration is into one of the large vessels of the mediastinum, or 
even into the oesophagus. 

The following is an example of bronchial phthisis, as it commonly 
occurs. This case, which is not included in the foregoing statistics, was 
seen almost daily by me during its entire progress. On September 3, 
1874, I examined an infant in the New York Infant Asylum, who had 
wheezing respiration during the last eight days. The wheezing occurred 
both on inspiration and expiration, and also, though less pronounced, 
during sleep; pulse 96, respiration 40, temperature normal. Its mother, 
who had charge of it, and had till recently wet-nursed it, had une- 
quivocal symptoms of tuberculosis for several months. The child was 
pallid, and its flesh was soft and flabby. The fauces were perhaps a 
little redder than usual, but were otherwise normal, and a careful ex- 
ploration of the chest revealed no cause of the embarrassed respiration. 
Auscultation and percussion gave a negative result. In the latter part 
of September a troublesome diarrhoea occurred, which continued more 
or less till near death. The temperature on September 28th, October 
8th, 10th, and 11th, was 100J°, 100°, 99 J, and 100°. The pulse on 
October 10th and 11th was 120 and 126." On October 8th the per- 

Fig. 20. 




cussion-sound over the upper part of the right lung seemed somewhat 
duller than on the other side, though the respiration was not observed 
to be notably changed in the area of the dulness. There was but little 
cough during the entire sickness. Death occurred on October 20th. 
At the autopsy the bronchial glands were found enlarged and cheesy, 
and underneath the right bronchus, near the bifurcation, was a softened, 
almost diffluent gland, as large as a small hickory-nut, and compressing 
the bronchus. This, no doubt, had produced the wheezing respiration, 
which had been the chief local symptom. The lungs, spleen, and in less 
degree the liver, contained numerous, small miliary tubercles. Certain 
of the mesenteric glands were also cheesy, but to a less extent than the 
bronchial. The disease of the bronchial glands was evidently primary > 



LUNGS. 163 

the tubercles of the lungs and abdominal organs being apparently quite 
recent. The accompanying woodcut, from a photograph by Mr. Mason, 
the photographer at Bellevue Hospital, represents a posterior view of 
the lungs and air-passages. 

In no case have I found tubercles in the heart or pericardium, though 
they have been observed in rare instances in the latter. The mesenteric 
glands were enlarged by hyperplasia, and more or less cheesy, in 30 
cases, were apparently normal in 2 cases, while in the remaining 4 
cases their condition was not stated. In most of the patients the mesen- 
teric glands were smaller and less cheesy than the bronchial, but in a 
few instances they were larger than the bronchial and more cheesy. 

It is a noteworthy fact, as bearing on the causative relation of these 
glands to tubercles, that not infrequently the amount of hyperplasia 
and cheesy degeneration occurring in the former was very considerable, 
while the tubercles in the lungs or elsewhere were small, even minute, 
semi-transparent, and evidently of recent formation. It appeared as 
if in such cases the glandular hyperplasia and degeneration, bronchial 
or mesenteric, or both, preceded the general tubercular disease, and 
probably sustained an etiological relation to it. Since the cases which 
furnished the above statistics occurred, my clinical experience with 
tuberculosis has greatly increased, but nothing new or different has 
been observed at autopsies. 

Abdominal Viscera. — In children, tubercles in the solid organs of 
the abdomen rarely give rise to appreciable symptoms, since they are 
small and disseminated, not impairing materially the function of the 
part in which they are located. On the other hand, peritoneal and 
intestinal tubercles, and the enlarged and cheesy mesenteric glands, 
give rise to symptoms which require description. The most frequent 
seat of peritoneal tubercles is upon the attached surface of the peri- 
toneum, where they are formed in the connective tissue. They are 
distinctly seen through the peritoneum, and cause some prominence of 
it. Exceptionally their seat is upon its free surface. Every portion of 
the peritoneum, whether visceral, parietal, or omental, is liable to tuber- 
cles, but generally tuberculization of so extensive a surface does not 
occur in any one case. The tubercles are spherical or lenticular, and 
most of them small. Sometimes they are very numerous, but so minute 
as to be scarcely visible. They are gray or yellow, according to the 
age. Peritoneal tubercles often produce circumscribed peritonitis, 
causing adhesion of opposite surfaces. The tubercles in themselves 
cannot be detected by palpation ; but masses or placques composed of 
tubercles and inflammatory products are sometimes so large that they 
can be felt through the abdominal walls. 

The symptoms of peritoneal tuberculosis are attributable, for the most 
part, to the peritonitis. Among them may be enumerated abdominal 
tenderness or pain, meteorism, ascites — usually slight — and derange- 
ment of the bowels, commonly diarrhoea. As tubercles in this situa- 
tion occur, in most cases, subsequently to tubercles elsewhere, the 
symptoms which have been described are associated with and are sub- 
ordinate to others. 

Stomach and Intestines. — The most common seat of gastro-intestinal 



lGi tuberculosis. 

tubercles is the small intestine, and more frequently its lower portion, 
near the ileo-caecal valve, than its upper or central. They are rare in 
the duodenum or contiguous part of the jejunum. They are developed 
ordinarily in the connective tissue, either that lying under the mucous 
or the serous surface. 

Gastro-intestinal tubercles are often accompanied by ulceration of the 
adjacent mucous membrane. But in a certain proportion of cases there 
is probably no causative relation of the tubercles to the ulcers, for 
ulceration of this membrane is not infrequent in the tuberculosis of 
children, when there are no tubercles in the walls of the stomach or 
intestines. The following statistics of Rilliet and Barthez, relating to 
this point, will aid to an understanding of the symptoms. 

Tubercles in walls of stomach, 7 cases, / w !£ u \ cer f ' 6 ca ! es « 

' ' ( without ulcers, 1 case. 

Ulcers of gastric mucous membrane, without gastric tubercles, 14 cases. 

Tubercles in small intestines, 82 cases, { w !^ ul f cer f' 70 c ^ es ' 

' ' t without ulcers, 12 cases. 

Ulcers without tubercles in small intestines, 51 cases. 

Tubercles in large intestine, 15 cases, / w !^ u l cer 1 s ' 10 c f es ' 

& ' ' \ without ulcers, 5 cases. 

Ulcers in large intestine, without tubercles, 47 cases. 

The ulcers have vascular, thickened, and infiltrated borders. Their 
diameters vary from a line to half an inch or more, and their general 
form is circular, or, if two or more unite, irregular. Tubercular ulcers 
of the stomach are mostly in the great curvature, those in the small intes- 
tines in the ileum and lower part of the jejunum, and those of the large 
intestine in the csecum. 

The following table exhibits the state of the principal abdominal 
viscera in the 36 cases embraced in my statistics : 

Liver. Spleen. Kidneys. 

Tubercular 12 22 1 

Non-tubercular 16 6 21 

Not stated 8 8 14 

Fatty 5 

In no instance did I observe tubercular softening in the abdominal 
organs, and a large proportion of the tubercles in the liver, spleen, and 
kidneys were still in the first stage. In the five cases in which the 
liver was recorded fatty, this state of the organ was obvious to the sight, 
as it is in tuberculosis of the adult. A moderate excess of fat in the 
hepatic cells may have been present in some of the other cases, but it 
was not sufficient to be appreciable without the microscope. It is to be 
remarked that in the five cases in which the liver was recorded fatty, 
this organ contained no tubercles. The spleen is seen to have been the 
most frequent seat of tubercles of all the viscera, except the lungs. In 
fourteen cases the intestines were examined ; and in five, tubercles dis- 
covered developed in their connective tissue. The intestinal tubercles 
were small, and ulceration had occurred of the mucous membrane which 
covered them. 

The brain was examined in fifteen cases. In twelve the amount of 



ABDOMINAL VISCERA. 165 

cerebrospinal fluid varied from gss to %v by estimation. In two 
others the records state that there was a considerable amount of this 
fluid, the exact quantity not being given, while in the remaining case 
congestion of the brain and meninges was noticed, but nothing was 
recorded in regard to the amount of cerebro-spinal fluid. The increase 
of the cerebro-spinal fluid in tuberculosis is attributable to wasting of 
the brain, a hydrocephalus ex vacuo, and in some cases to passive con- 
gestion and serous transudation, due to feeble circulation, or obstructed 
flow from the pressure of bronchial glands on the vessels within the 
thorax, as already stated. 

Tubercles were present in the pia mater in three cases : in two with 
fibrinous exudation ; in the other without fibrin or other evidence of in- 
flammation. Tubercular meningitis is described in another part of this 
book. 

Symptoms. — The symptoms in tuberculosis of children arise in part 
from the diathesis, and in part from the tubercles. Before the period 
of tubercles, there are signs of failing health, such as loss of appetite, 
flabbiness of the soft parts, or emaciation, lassitude, and loss of 
strength. These symptoms continue after the formation of tubercles, 
and increase. 

The features are ordinarily pallid, but during the paroxysms of fever, 
to which tubercular patients are subject, they may be flushed. Lividity 
of the features, due to imperfect decarbonization of the blood, occurs, 
if there be enlarged bronchial glands which compress the vessels within 
the thorax, or if there be extensive pulmonary tuberculization, or pul- 
monary tuberculization, whether extensive or not, which is complicated 
by capillary bronchitis or pneumonia. 

The skin is nearly natural, or it loses its flexibility and softness, and 
becomes dry and rough. In some patients there is, at times, general 
or partial furfuraceous desquamation of the skin, due to exaggerated 
development of the epidermis. Children, like adults, notwithstanding 
the general dryness of the surface, are liable to perspirations at night 
and in sleep. This symptom is less frequent at the commencement 
than at an advanced period, and in acute than in chronic cases, in 
young, namely, those under three or four months, than in older children. 
It is more abundant about the head and limbs than elsewhere, and is 
sometimes confined to these parts. 

Anasarca is not infrequent. It sometimes arises from obstructed 
circulation, in consequence of compression of the thoracic vessels by 
enlarged lymphatic glands; in other cases it is due to diminished plas- 
ticity of the blood, a result of the tubercular cachexia. The latter is 
the more common cause. It is not an important symptom, on account 
of the small amount of serous transudation, and the character of the 
parts in which it occurs. 

Emaciation, already alluded to, is early, constant, and progressive. 
Under the age of six or eight months it is less marked than in older 
children, many preserving considerable rotundity of features and form 
even in advanced tuberculosis. The failure of the strength corresponds 
in amount and progress with the emaciation. Slight at first, and ex- 
hibited only by a degree of lassitude, it gradually increases, till for 



166 TUBERCULOSIS. 

weeks before death the little patient is fatigued by the ordinary mus- 
cular movements, and is disposed to keep quiet. 

The nervous system is not ordinarily affected except in cases of intra- 
cranial tubercles. In acute tuberculosis, or tuberculosis complicated 
by severe inflammation, there may be agitation and delirium, especially 
at night. 

In most patients the mucous membrane of the buccal cavity presents 
its normal appearance, with the exception of a moist fur upon the 
tongue, and a paler hue than normal of its surface generally. In acute 
tuberculosis, and in cases complicated by inflammation, the tongue is 
sometimes dry and brown. The appetite may be normal till the close 
of life, or it is poor or changeable. Occasionally it is increased, 
although the disease is progressing. The bowels are regular or relaxed. 
Diarrhoea may be a prominent symptom, even when there are no intes- 
tinal tubercles or ulceration. Meteorism and fulness of the abdomen 
are common. 

Fever, constant, but usually with evening exacerbation, is rarely 
absent. It continues for weeks or months. During the exacerbation 
the pulse rises to 120, 140, or even to 180 beats per minute, and there 
is a corresponding exaltation of the temperature, which in the latter 
part of the day, without inflammatory complication, ranges from 100° 
to 102° or 103°. The febrile movement is a symptom of diagnostic 
value as regards the nature of the disease, though it does not indicate 
the seat of the tubercles. 

In addition to the symptoms now described, there are special symp- 
toms, due to tuberculization of the different organs. In young children, 
on account of the fact already referred to, to wit, the tendency to a 
generalization of tubercles, there is apt to be a blending of the symptoms 
which arise from different organs, but with care it is not difficult in most 
instances to isolate and refer them to their proper source. The following 
are the symptoms which arise from tuberculization of the more im- 
portant organs. 

Encephalon. — The symptoms produced by tubercles of the encephalon 
vary according to their seat and size, and the structural changes in sur- 
rounding parts to which they give rise. Meningeal tubercles, which 
are located for the most part in the meshes of the pia mater, and 
ordinarily along the course of the small arteries', are, as a rule, small, 
not more than a line in diameter, and they may remain latent for a 
considerable time. In the majority of cases, however, they sooner or 
later cause meningitis, the symptoms of which are well known and need 
not be described. But tubercles in this situation do sometimes give 
rise to symptoms when there is no meningeal inflammation. They 
occasion congestion of the surrounding vessels, and serous transudation, 
and, if developed on the under surface of the pia mater, they may pro- 
duce symptoms by encroaching upon and irritating the brain; for they 
are sometimes so much embedded in the convolutions that careful exam- 
ination is required in order to determine that they are meningeal, and 
not cerebral. Among these symptoms may be mentioned headache, 
frontal or occipital, sometimes intermittent, nausea, melancholy, and in 
certain cases the symptoms produced by serous transudation. 



EXCEPHALOX. 167 

The symptoms of cerebral are in part similar to those of meningeal 
tubercles, but in most cases others of a neuropathic character are 
present, which serve for differential diagnosis. The differences as 
regards the symptoms of different patients affected with cerebral tuber- 
cles are attributable in part to the fact that their size and rapidity of 
growth vary, but more to the difference in their seat ; for any part of 
the brain may be the seat of tubercles, though certain portions, as the 
cerebellum, are more frequently affected than others. 

The child with cerebral tubercles is quiet, but irritable and easily 
excited. Delirium is not common, but many before the close of life 
exhibit a decree of mental dulness. The headache, common in cases 
of cerebral as well as meningeal tubercles, may be nearly general, or it 
is frontal, parietal, or occipital, according to the seat of the tubercles. 
It is often lancinating, often intermittent. 

Clonic convulsions occur toward the close of life. Exceptionally 
they are among the earliest symptoms. Observations have failed to 
establish any relation between the seat of the tubercles and the locali- 
zation of the convulsions. The convulsions may be unilateral, while 
the tubercles are in both hemispheres ; or general, while the tubercles 
are on one side only. 

The severity and duration of the convulsive attacks, and the frequency 
of their occurrence in tuberculosis of the brain, vary greatly in different 
patients. They have been attributed to softening of the cerebral sub- 
stance, which sometimes occurs immediately around the tubercles, to 
local congestions excited by them, and also to serous effusions in the 
ventricles. The convulsions, sooner or later, end in paralysis or coma. 

Contraction, or tonic convulsion of certain muscles, is sometimes 
observed. Its most frequent seat is in the muscles of the back, and of 
one or both of the lower extremities. It is a late symptom. ■ It occurs 
in those cases in which there is softening around the tubercles, and 
usually in the muscles of the opposite side. 

Paralysis is also a late, but not an infrequent symptom. It is pre- 
ceded by headache, and sometimes, as already stated, by convulsions. 
Occurring as a symptom of tuberculosis of the brain, it is due either to 
pressure on a cranial nerve, or to compression and perhaps softening of 
the cerebral substance. The paralysis may be paraplegic, commencing 
as feebleness of the lower extremities, and increasing until it becomes 
complete, or a more or less complete, hemiplegia. In paraplegia due 
to tubercles of the brain, the cerebellum is, as a rule, their seat ; while 
paralysis of one side, or of certain muscles of one side, indicates tuber- 
cles of the opposite cerebral hemisphere ; but there are exceptions. 
Paralysis of the third cranial nerve gives rise to ptosis, of the sixth to 
paralysis of the external motor nerves of the eye, and therefore to in- 
ternal strabismus. 

Feebleness or loss of vision, inequality, oscillation, and finally dilata- 
tion of the pupils, are not infrequent symptoms of tuberculosis of the 
brain, and they possess great diagnostic value. Atrophy of the optic 
nerve, causing amaurosis, sometimes results from tubercles as well as 
other tumors of the brain. Atrophy of this nerve occurs not only 
when the tubercles are so located as to press on the optic tract, in 



1(38 TUBERCULOSIS. 

which case the explanation is apparent, hut also, in certain patients, 
when the tuhercles are in other parts of the brain. In these last cases 
it is thought by Brown-Sequard and others that the imperfect nutrition 
of the nerve is due to contraction of its nutrient vessels, produced by 
the tubercles through reflex action. 

In tuberculosis of the brain, symptoms pertaining to the respiratory, 
circulatory, and digestive systems are either absent or are quite sub- 
ordinate to those of a neuropathic character. Slowness of the pulse, 
with or without intermittence, has sometimes been observed, and it is 
therefore a symptom of some diagnostic value. Toward the close of 
life both pulse and respiration are apt to be accelerated. Yomiting, 
constipation, and retraction of the abdomen, which are so common in 
meningitis, are only occasional symptoms. 

Bronchial Glands. — During the progress of tuberculosis, hyper- 
plasia, cheesy degeneration, and softening of various lymphatic glands 
may occur throughout the body, but the bronchial and mesenteric 
are not only those which are most frequently affected, but they are the 
only glands, unless in exceptional instances, which materially increase 
the- danger or give rise to special symptoms. These symptoms either 
have a mechanical cause, namely, the pressure exerted by the enlarged 
glands on contiguous parts, or they are due to softening of the glands 
and consecutive inflammation and ulceration. 

The following are the principal symptoms due to compression. Some 
of them are not infrequent, others are rare. Compression of the pul- 
monary veins retards the flow of blood from the lungs to the left auricle, 
giving rise to congestion, and, in extreme cases, oedema of the lungs, 
with sanguineous extravasation into the lung-substance, congestion of 
the right cavities of the heart, hepatic veins, and of the systemic 
capillaries generally. Compression of the pneumogastric nerve, or of 
the recurrent laryngeal, which is the motor nerve of the laryngeal 
muscles, modifies the voice, and produces a cough which is apt to be 
spasmodic. The cough resembles that of pertussis, and has been mis- 
taken for it, but it is not so violent or protracted. The voice, clear 
and natural at first, becomes by degrees hoarse or feeble from deficient 
innervation of the laryngeal muscles. 

An enlarged gland, or mass of glands, lying against the trachea or 
one of the bronchial tubes (this may occur with tubes up to the third or 
fourth division), and pressing its walls inward, obviously obstructs more 
or less the current of air. If there be considerable obstruction, a loud, 
sonorous rale is produced, which is heard distinctly at a distance from 
the chest, obscuring other rales. It is loudest when the patient is 
agitated, and it sometimes intermits. Feeble respiratory murmur, 
dyspnoea, and a cough are not infrequent in bronchial phthisis. Di- 
minished intensity of the respiratory murmur is general or partial, 
according to the seat of the compression. It has been most frequently 
observed at the summit of the lungs. In certain patients this symp- 
tom is not constant, the respiration being for a time feeble and then 
normal. The dyspnoea may be a prominent and distressing symptom, 
the alse nasi dilating, and the inframammary region sinking w T ith each 
inspiration. The cough which occurs when a gland presses on the 



LUNGS. 169 

trachea or bronchial tube, is due to the tracheitis or bronchitis to which 
the pressure gives rise. If ulceration occur at the point of pressure, 
the cough continues as long as the ulcer remains. Compression of the 
large veins within the thorax, which return blood from the head and 
upper extremities, causes more or less congestion of these parts, with, 
perhaps, transudation of serum in the subcutaneous connective tissue, 
and within the cranium. Barely, a softened gland by ulceration gives 
rise to other symptoms than those mentioned, namely, hemorrhage by 
ulceration into a vessel, or pleuritis or pneumonitis if the ulceration be 
toward the lungs. 

Improvement in the condition of the patient affected with bronchial 
phthisis is not unusual. It may be permanent, but in most patients it 
is temporary, so that in a few weeks or months the symptoms are as 
severe as before. The improvement is due to softening and elimination 
of a gland which had given rise to symptoms by its mechanical effect, 
or by the inflammation which it had excited. 

Physical Signs. — These are absent or obscure in the incipient dis- 
ease, when the glands are small, and they are most marked in those 
cases in which the glands are so large as to press on the thoracic walls, 
since they then become the medium for the transmission of sounds to 
the ear. The part of the thorax against which they most frequently 
press is the dorsal vertebras, from the first to the sixth, and each side 
of the vertebrae, and less frequently the upper third of the sternum. 
The physical signs are dulness on percussion over the interscapular 
space, and perhaps, though to a less extent, over the upper part of the 
sternum, and bronchial respiration in the same situations. Occasionally 
a bruit can be detected, due to the nressure of a gland on one of the 
large vessels of the chest. 

Lungs. — A cough is one of the earliest and most persistent of the 
symptoms of pulmonary tuberculosis. It is so rarely absent, that those 
of large experience do not meet with more than one or two such cases. 
It varies in severity and frequency. If the tuberculosis be acute and its 
course rapid, the cough, even from its commencement, is frequent, so as 
to weary the patient and deprive him of needed rest. But in ordinary 
cases, that is, when the disease is chronic, it commences gradually, at- 
tracting little attention by its infrequency, but becoming more frequent 
and painful as the malady advances. 

Ordinarily the cough is dry in the first weeks or months, but it 
becomes looser in the course of the disease, from the greater amount of 
bronchial inflammation. In exceptional instances it has a spasmodic 
character, like that produced by pressure of an enlarged bronchial gland 
on the pneumogastric or recurrent laryngeal nerve. This occurs from 
the accumulation of viscid mucus in one or more of the bronchial tubes, 
usually in dilated portions of them, from which it is with difficulty ex- 
pectorated. 

The respiration in pulmonary tuberculosis is accelerated in proportion 
to the degree of tuberculization. Tuberculization of a considerable part 
of both lungs gives rise to dyspnoea, especially when, as is ordinarily the 
case, bronchial, pulmonary, or pleuritic inflammation has supervened. 
Pneumonitis or pleuritis gives rise to the expiratory moan, and as these 



170 TUBERCULOSIS. 

inflammations, when induced by tubercles, are protracted, this symptom 
may continue for weeks or months. 

Patients under the age of six years do not expectorate, or but rarely. 
After this age expectoration is not common in the commencement of 
pulmonary tuberculosis, but in the confirmed disease it is a pretty con- 
stant attendant of the cough. Haemoptysis is also rare under the age 
of six years, and less frequent subsequently than in the adult. It is 
most apt to occur in those cases in which there is already passive con- 
gestion of the lungs, produced by the pressure of enlarged bronchial 
glands in the manner already described. Patients old enough to make 
known their subjective symptoms, sometimes complain of fugitive pains 
under the sternum or between the shoulders. 

In young children the physical signs of incipient pulmonary tubercu- 
losis are wanting, or are so obscure as not to be readily recognized. 
This is due to the small size and dissemination of the tubercles. In 
older children the physical signs appear early, and are readily recog- 
nized, because, as a rule, the tubercles are aggregated, and are more 
frequently at the apices of the lungs as in the adult, than elsewhere. 
In the advanced disease, whether in infancy or childhood, when inflam- 
mation and more or less destruction of the lung substance have occurred, 
the physical signs, so far from being obscure, enable us in most cases, 
in connection with the history, to make an immediate and positive 
diagnosis. 

In young children affected with pulmonary tuberculosis the irregular 
and imperfect expansion of the lungs produces by degrees changes in 
the shape of the thorax, which are apparent on inspection. In some, 
the lungs being habitually imperfectly inflated, the obliquity of the ribs 
is increased, and the thorax consequently elongated, while its antero- 
posterior and transverse diameters are diminished. This obviously in- 
creases the convexity or arch of the diaphragm, so that this muscle 
sometimes lies against the thoracic walls as high as the ninth or even 
eighth rib. If the costal cartilages are yielding, there are anterior flat- 
tening of the chest and depression of the sternum ; if they are firm, on 
account of the more advanced age, the chest remains circular. 

Another shape of the thorax is not infrequent in feeble tubercular 
children, especially infants, who have suffered from repeated attacks of 
"bronchitis. It occurs also in the non-tubercular, if the conditions which 
favor it are present. The conditions are, on the one hand, feebleness 
of the patient, with diminished force of respiration and impaired resi- 
liency of the ribs ; and, on the other, obstruction by mucus of one or 
more of the bronchial tubes. Occlusion, more or less complete, of a 
bronchial tube, and consequent obstruction to the current of air, pro- 
duces a corresponding degree of collapse in the portion of lung to which 
the tube leads. The parts which collapse are, in most cases, the' lower 
lobes, and the thin anterior margins of the upper lobes. This causes 
lateral depression of the lower ribs, except such as are pressed outward 
by the abdominal viscera, and an anterior projection of the lower part 
of the sternum. The shape of the thorax in these cases differs from 
that in rachitis, in the fact that the lateral depression does not extend 
to the upper ribs, nor does the upper part of the sternum project. 



PLEURA. 171 

Certain precautions should be observed in examining the chest by 
percussion and auscultation. The child should sit or recline, with the 
arms and shoulders in the same position, and the axis of the trunk 
straight. Inclination of the trunk to either side, raising or depressing 
a shoulder, may produce an appreciable difference in the two sides as 
regards the physical signs. Percussion of the two sides should be prac- 
tised at the same stage of respiration. A slight difference in the degree 
of resonance does not afford proof of disease, unless it be observed at 
different examinations ; for, in feeble children, it often happens that all 
portions of the lungs do not expand alike, so that where we have noticed 
slight dulness at one visit, it may by the next have disappeared, or even 
at the same visit, if forcible inspirations be excited. 

The physical signs ascertained by palpation, auscultation, and per- 
cussion are, as in the adult, vocal fremitus, bronchial respiration, 
bronchophony, and dulness on percussion. In these cases in which the 
tubercles are mainly at the apices of the lungs, diminished expansion 
of the infraclavicular region is observed during inspiration, and this 
part of the thoracic wall is permanently depressed, so that the clavicles 
are unusually prominent. If there be emphysema, this flattening does 
not occur, or is slight. Dulness on percussion, though more frequently 
observed in the infraclavicular region than elsewhere, may be present 
in different isolated places. If pneumonia supervene, the dulness not 
infrequently extends over a considerable part of one lung. The cracked- 
pot sound is often observed on percussion, but it possesses no diagnostic 
value. It can be produced, when there is no pulmonary disease, by 
percussion over a bronchus. 

Bronchial respiration and bronchophony are important signs, as 
indicating solidification of the lung, but they do not show whether the 
solidification be tuberbular or pneumonic, or the two conjoined. This 
must be determined by the history of the case, the extent of surface 
over which these signs are heard, and their persistence. When the 
tubercles begin to soften, and the lung-tissue breaks up, moist rales 
appear, often hoarse and gurgling, obscuring the bronchial respiration. 
A cavity in the lung, or pneumothorax, is attended by the same physical 
signs as in the adult. 

Pleura. — Little need be said in reference to the symptoms and 
physical signs of tuberculosis of the pleura, since this affection is in 
most instances associated with tuberculosis of the lungs, and is not 
distinguishable from it. But now and then the pleural tubercles are 
numerous and large, giving rise to symptoms, while those of the lungs 
are small, few, and without symptoms, or attended by symptoms which 
are quite subordinate. Either the costal or visceral portion of the 
pleural may be the seat of tubercles. They are developed directly under 
the pleura, or upon its free surface. They are very apt to occur in the 
newly formed connective tissue which results from pleuritis. Those 
located upon the free surface, or under the costal pleura, rarely soften, 
while those under the visceral pleura sometimes soften and cause ulcer- 
ation. Occasionally numerous aggregated tubercles form a firm con- 
tinuous layer upon the surface of the pleura, preventing, if upon the 
visceral pleura, full expansion of the lung. This may give rise to a 



172 TUBERCULOSIS. 

degree of dulness on percussion, and feebleness of the respiratory mur- 
mur. Ordinarily, however, in this form of tuberculosis, the symptoms 
and physical signs, so far as any are observed, are due to the pleuritic 
inflammation which the tubercles excite. 

Stomach and Intestines. — The symptoms in tuberculosis of the 
stomach and intestines vary according to the seat and stage of the 
tubercles. 

Tubercles, whether gastric or intestinal, are not at first accompanied 
by symptoms, or the symptoms are obscure and ill- defined. Symptoms 
arise when inflammation occurs in the adjacent tissues. Diarrhoea is 
one of the most common and persistent of the symptoms. The alvine 
discharges are brown and thin, and sometimes, in advanced cases, very 
offensive. They may be streaked with blood which has escaped from 
the ulcers. Intestinal tubercles, developed immediately underneath 
the peritoneal coat, sometimes cause local peritonitis, usually of little 
extent. This gives rise to circumscribed pain, tenderness, and more or 
less meteorism. 

Diagnosis. — It is evident from the foregoing description of symptoms 
that the diagnosis of incipient tuberculosis is much more difficult in 
children than adults. Before commencing the examination, it is best 
to learn the hereditary tendencies of the family and the history of the 
patient, especially as regards antecedent diseases or debilitating agen- 
cies, and the duration of the symptoms. 

Early and accurate diagnosis of tuberculosis in the child, as well as 
in the adult, is now rendered possible by the discovery of the tubercle 
bacillus, in 1882, by Koch. This bacillus abounding in the sputum, 
as well as in the affected organs of phthisical patients, having a slender 
rod-like form, having a length varying from one-fourth to the entire 
diameter of the red blood-corpuscles, and susceptible of a peculiar 
staining by the aniline colors, which differentiates it from all other 
bacilli, is, as we have stated above, believed to be uniformly present in 
tuberculosis, and absent in other conditions. 

Children with tuberculosis of the lungs expectorate comparatively 
little, but sufficient sputum can probably be obtained in most instances 
for the purpose of diagnosis. The presence of the bacillus indicates 
clearly the tubercular nature of the disease. 

Tuberculosis of the encephalon is diagnosticated with more difficulty 
than that of the thoracic or abdominal organs ; but certain of these organs 
are in most patients tubercular at the same time, and the knowledge of 
the fact that they are affected aids in the diagnosis of the disease of the 
brain or its meninges. Among the symptoms of intracranial tuber- 
culosis which possess diagnostic value may be mentioned cephalalgia 
and more or less fever, with exacerbations in the commencement of the 
disease, and, at a more advanced period, strabismus, inequality or 
irregular action of the pupils, impairment of vision, retraction of the 
head, and convulsive movements or paralysis. 

In certain cases careful observation and discrimination of symptoms 
are requisite, in x>rder to determine whether they arise from intracranial 
tubercles, or from congestion of the brain caused by obstruction in the 
venous circulation by the pressure of enlarged bronchial glands. 



DIAGNOSIS 



173 



The diagnosis of bronchial phthisis, when the glands are still small, 
is necessarily uncertain, on account of the absence of symptoms. When 
they have increased in size and are so located as to press on the pneu- 
mogastric or recurrent laryngeal nerve, producing the spasmodic cough 
already described, the differential diagnosis between that disease and 
pertussis may be made by attention to the following facts : Bronchial 
phthisis occurs singly, and is non-contagious, while pertussis occurs as 
an epidemic, and with evidences of contagion. There are no successive 
stages, to wit, those of catarrh, paroxysmal cough, and decline, as in 
that disease, and the cough, though paroxysmal, is short, and without 
whoop or vomiting. 

In feeble children, with inherited tubercular diathesis, emaciation, 
sweats, and a chronic cough, with the absence of pulmonary symptoms, 
should excite suspicions that the bronchial glands are involved. The 
evidence is almost conclusive if the cough become paroxysmal, and 
there be a loud, persistent tracheal or bronchial rale. 

Fig. 21. 




Bacillus tuberculosis. (Sternberg ) 

In certain patients affected with this form of tuberculosis, we have 
seen that the prominent symptoms are due to compression of one or 
more of the large vessels in the chest. Compression of these vessels, 
and consequent retarded circulation, may be confidently referred to en- 
larged bronchial glands, since aneurism, carcinomatous or other tumors, 
which would produce a similar result, are very rare before puberty. 
Sometimes the diagnosis is rendered certain by the physical signs 
observed by auscultation, and percussion over the sternum and the 
interscapular space. The condition of the external glands should also 
be observed, as those of the axilla, neck, and groin. 



174 TUBERCULOSIS. 

The diagnosis of pulmonary, though more readily made than that of 
intracranial and bronchial tuberculosis, is often difficult and uncertain. 
This is, in part, explained by the fact that the tubercles are so fre- 
quently disseminated, while emaciation and a chronic cough are not in- 
frequent from other causes than tubercles. Rachitis, intestinal worms, 
dentition, simple tracheal or bronchial inflammation, may be attended 
both by a chronic cough and emaciation. Caution is therefore requisite 
in order to avoid a grave error in diagnosis. Precipitancy in the diag- 
nosis of doubtful cases is worse than indecision, and it is often best to 
postpone an expression of opinion as to the nature of the disease, till 
the case has been observed a few days. 

The significance and importance of the symptoms, physical signs, and 
other facts on which a diagnosis must be based, have already been suffi- 
ciently pointed out. It is difficult, in fact in certain cases impossible, 
to discriminate by the physical signs between simple cheesy pneumonia 
and cheesy pneumonia which has ended in the formation of tubercles. 
The patient has an attack of catarrhal pneumonia ; but, instead of 
absorption of the inflammatory product, cheesy infiltration occurs, and 
the lung in places becomes infiltrated with pus, softens, and breaks down. 
The patient presents the symptoms and physical signs of phthisis. He 
may recover after a protracted sickness, or may die. The disease may 
remain a pneumonia ; but this is a condition of the lungs which favors 
the development of tubercles, and in a certain proportion of cases tuber- 
cles do form in the last weeks of life. Though the differential diagnosis 
in such cases between cheesy pneumonia and tuberculosis supervening 
on pneumonia is impossible, practically the discrimination is unimportant, 
as the same treatment is required. 

Advanced pulmonary tuberculosis, except when it supervenes upon 
pneumonia, can in most instances be readily diagnosticated by a careful 
examination. Still, it is to be recollected, as already pointed out, that 
certain of the symptoms and physical signs, which occurring in the adult 
would afford almost positive proof of pulmonary tuberculosis, not infre- 
quently have a different origin in children. 

The diagnosis of tubercles in the abdominal organs is facilitated by 
the presence of symptoms which indicate at the same time tuberculosis 
of the lungs. Among the' chief diagnostic signs of tuberculosis of the 
peritoneum may be mentioned meteorism and a degree of tenderness on 
pressure, but there is danger of mistaking the tympanitic state of the 
intestines common in ill-nourished infants and the rachitic, or the ful- 
ness due to enlarged spleen or liver, for that occasioned by peritoneal 
tuberculization, and vice versa. The history of the case, and a careful 
examination of accompanying symptoms, and the shape and feel of the 
addomen, usually suffice to establish the diagnosis. In simple gaseous 
distention of the abdomen there is an absence of the symptoms, general 
and local, which attend tuberculosis ; rachitis occurs at an earlier age 
than peritoneal tuberculosis, and digital examination, aided by percus- 
sion, enables us to diagnosticate enlargement of the liver or spleen. 

Tubercular enlargement of the mesenteric glands cannot be positively 
diagnosticated when they are small. When they have attained such a 
size that they can be felt through the abdominal walls, palpation, in 



TREATMENT. 175 

connection with the history and symptoms of tuberculosis, suffices to 
establish the diagnosis. The glandular tumors can be diagnosticated 
from other tumors by the fact that they are tender on pressure, and 
occupy the umbilical region, while fecal tumors are not tender, and are 
located in the iliac or lumbar region. Gastro-intestinal tuberculosis 
cannot be positively diagnosticated. Protracted diarrhoea, or frequent 
attacks of diarrhoea, not readily controlled by medicine, and occurring 
in tubercular cases, are probably associated with intestinal ulceration ; 
but in only a certain proportion of cases of ulceration are there also 
tubercles in the walls of the intestines, as we have seen above. 

Prognosis. — Death is the ordinary result of tuberculosis in the 
child, as it is in the adult ; but now and then one recovers. Hospital 
statistics show that the average duration of the disease is from three to 
seven months. Under favorable circumstances it is more protracted, 
even to two or three years. Those succumb soonest who inherit a 
strongly marked tubercular diathesis, live in damp, dark, and ill-venti- 
lated apartments, and whose diet is scanty or of poor quality. There- 
fore in the poor quarters of the city tuberculosis presents a worse form 
and pursues a more rapid course than among families in better circum- 
stances. 

Favorable prognostic signs are absence of tubercular diathesis, good 
appetite and general health, with little emaciation, infrequency of cough, 
with respiration, pulse, and temperature nearly normal. Such symp- 
toms may afford hope of recovery with judicious regimenal and thera- 
peutic measures. On the other hand, if the symptoms be grave, death 
is inevitable, unless in bronchial phthisis, in which, even when there is 
considerable urgency of symptoms, the offending gland is sometimes 
eliminated by softening and ulceration, and the patient improves tempo- 
rarily, if he do not ultimately recover. Complete and permanent 
recovery is, however, quite exceptional. 

Death in tuberculosis of children may occur from exhaustion induced 
by the general disease, or from the local effects of the tubercles. Thus, 
in intracranial tuberculosis it may result from meningitis ending in 
convulsions and coma; in pulmonary tuberculosis, from dyspnoea, 
though more frequently from exhaustion ; in that of the bronchial 
glands, from dyspnoea or hemorrhage ; in that of the abdominal organs, 
from peritonitis or protracted diarrhoea. 

Treatment. Prophylactic. — Since caseous substance occurring in 
some part of the system is a common cause of the development of 
tubercles, it is evident that measures which tend to prevent the occur- 
rence of this substance are prophylactic of tuberculosis ; and since, in 
children, cheesy matter, in most instances, is a product of strumous in- 
flammations, the anti-strumous remedies are demanded in the prophy- 
lactic as well as curative treatment of tuberculosis. Therefore, the 
strumous child should be watched with great care, and such measures be 
employed as are calculated to invigorate his system. If the mother 
belong to a decidedly tubercular family, or give the history of scrofula 
in her childhood, it is better that she do not suckle her infant, but 
employ a healthy wet-nurse. Children who are weaned should have 
plain, but nutritious and easily digested diet, a part of which should 



176 TUBERCULOSIS. 

be milk. Residence in an airy and salubrious locality, outdoor life, a 
scrupulous avoidance of exposure by which cold might be contracted, 
are important, in order to the continued latency of the diathesis. 

Loss of flesh or appetite, or other evidences of failing health, indi- 
cate the need of other measures of a therapeutic character. Alcoholic 
stimulants should now be allowed three or four times daily in milk : 
cod-liver oil, with half its quantity of syrup of the lactophosphate of 
lime, to which the syrup of the iodide of iron is added, will be found 
useful for these cases, as it is in the ordinary forms of scrofula. The 
various bitter preparations containing iron, as the citrate of iron and 
quinine, elix. calisaya bark with iron, etc., should be employed, when, 
for any reason, cod-liver oil is not tolerated. By the employment of 
such precautionary measures as soon as indicated, multitudes of children 
might be saved from tuberculosis who now perish. 

Curative. — The medicinal agents which are required in ordinary 
cases have been already mentioned, namely, cod-liver oil, iron, some- 
times the vegetable tonics, and alcoholic stimulants. The oil may be 
given in emulsion to disguise the unpleasant flavor, or, which I prefer, 
mixed with half its quantity of syrup of the lactophosphate of lime, as 
recommended for the treatment of scrofula. 

If the cod-liver oil be not tolerated, or if it impair the appetite, it 
should be discontinued. In cases of diarrhoea it is of little or no benefit 
and may do harm. Under such circumstances patients sometimes do 
better with simple regimenal measures, aided by alcoholic stimulants, 
and one of the least unpleasant of the tonics, as wine of iron or the 
calisaya bark. The regimen already recommended for prevention is 
also required as part of the curative treatment. 

Certain modifications of treatment are demanded on account of the 
localization of the tubercles. Intracranial tuberculosis, as soon as 
diagnosticated, should be treated by pretty decided doses of iodide of 
potassium, though, unfortunately, there is little prospect of improve- 
ment. The glandular disease, whether bronchial or mesenteric, requires 
the iodide of iron, with or without that of potassium. Pneumonitis or 
pleuritis, so frequent a complication of pulmonary tuberculosis, requires 
emollient poultices, with moderate counter-irritation, and the judicious 
rise of opiates with stimulants. The peritonitis occurring in abdominal 
tuberculosis, which is usually circumscribed, is best> treated by fomenta- 
tions and poultices, with opiates, and the diarrhoea by subnitrate of 
bismuth and chalk, five to ten grains of each, or the bismuth with 
Dover's powder, or a more active astringent. 



ETIOLOGY. 177 



CHAPTEE IY. 

SYPHILIS. 

Syphilis in infancy and childhood presents itself under two forms, 
namely, the congenital and acquired; the former is the more frequent. 

Etiology. — Congenital syphilis may be derived from either father or 
mother. Either parent, having previously had syphilis, may transmit it 
to the offspring, although at the time free from syphilitic symptoms. 
The mother, healthy at the time of conception, but infected with syphilis 
prior to the eighth month of gestation, may communicate the disease 
to the foetus ; syphilis contracted in the eighth or ninth month does 
not affect the foetus. If both parents have syphilis, the infant is almost 
necessarily syphilitic; on the other hand, if only one parent be affected, 
the infant may or may not be contaminated. Sometimes, with such 
parentage, a part of the children are syphilitic, and a part healthy. 

Acquired syphilis in infancy and childhood may be received through 
primary lesions — that is, by reception of the virus from a chancre or 
bubo ; or it may be derived from certain of the secondary lesions. In- 
oculation by primary lesions may occur at the birth of the infant, from 
a syphilitic sore in the vagina or upon the vulva of the mother; inocu- 
lation in this manner is, however, rare. Children may also receive the 
virus from primary lesions on the persons of nurses or companions. 
Infection in this manner is sometimes accidental, and sometimes the 
result of criminal conduct. A chancre on the breast of the wet-nurse 
not very infrequently communicates syphilis to the nursling. 

The contagiousness of "secondary manifestations," for a long time 
doubted, is now fully established. Syphilis may be communicated by 
the secretion or exudation of a mucous patch, or a secondary sore. 
Hence the danger of lactation by unhealthy wet-nurses, though they 
present no symptoms of recent syphilis. Excoriations or sores upon 
the nipple or breast of an infected wet-nurse may communicate the 
disease to the nursling ; and, on the other hand, mucous tubercles or 
fissures upon the lips or tongue of the infected infant may be the means 
of contaminating a healthy wet-nurse. Many such cases are now con- 
tained in the records of medicine. Vaccination by means of the scab 
is also a mode by which constitutional syphilis may be communicated. 
For further particulars in reference to this subject the reader is referred 
to our remarks on vaccination. 

The specific principle of syphilis is unknown. Klebs obtained by 
cultivation bacilli from rods and spherules which he found in indurated 
chancres. With the cultivated bacilli he produced a local affection by 
inoculation in the monkey, which resembled, in some respects, that of 
syphilis, and in other respects that of tuberculosis. Ziegler and von 
Rinecker obtained negative results from similar experiments. (Ziegler's 
Path. Anatomy.) 

12 



178 SYPHILIS. 

Clinical History. — The effects of the syphilitic poison upon the 
development of the foetus, and the development and health of the infant, 
are different in different cases. The foetus, under the influence of the 
poison, often ceases to grow, shrivels, dies, and is expelled, long before 
term ; or it may be born alive, but prematurely, and showing clear evi- 
dences of the disease, as soon as it comes into the world ; or, again, it 
may be born at term, but dead. So frequently is syphilis a cause of 
non-viability, that, as Trousseau has remarked, this disease should be 
suspected as the cause, whenever a woman repeatedly aborts. Abortion 
from syphilis commonly occurs at or about the sixth month of gestation. 
In those cases in which the foetus dies from syphilis there is often 
placental syphilitic disease, namely, an undue growth of cells in the 
villi, which, compressing the vessels, gives rise to fatty degeneration, 
and prevents the requisite interchange between the maternal and foetal 
blood. (Harring, Frankell.) Frank ell designated the change " granu- 
lation-cell hypertrophy of the placental villi." Virchow, in one case 
found a gummy tumor in the maternal portion of the placenta. 

When a foetus destroyed by syphilis is expelled, it is apt to present a 
macerated appearance, the cuticle being detached over large patches of 
surface, and in other parts raised in blebs, with a thin, puriform, and 
offensive fluid underneath ; the liver is occasionally indurated, and ab- 
scesses with spots of inflammation are sometimes observed in the thymus 
gland; the amniotic fluid is offensive, turbid, and of a greenish or 
greenish-brown appearance. 

If the foetus, in which syphilitic manifestations have begun to occur, 
have reached a viable age, and be born alive, it is small and imperfectly 
developed, often shrivelled and senile in appearance. The skin looks 
unhealthy, and it may exhibit a distinct rash. Bouchut saw a seven 
and a half months' infant born alive, with an eruption of a copper color 
upon the legs and arms, and onyxis upon the fingers and toes. The 
bullae of pemphigus are also not infrequent upon the skin at birth, or 
they appear within a few days, two or three, after birth. The smallest 
are about the size of a split pea ; but many are considerably larger ; the 
largest consist of two or more which have coalesced. They contain a 
thin, greenish, purulent matter, and appear most frequently upon the 
palms of the hands and soles of the feet, but also in severe cases upon 
the face and over the surface of the body. Recently I was able to 
diagnosticate syphilis in an infant within a day after birth, by its small 
size and feebleness, and the appearance of large blebs of pemphigus 
upon its hands, feet, fingers, and toes, over which the skin soon broke, 
leaving troublesome and bleeding sores ; coryza commenced about the 
twelfth day. The parents seemed healthy, but I was enabled to trace 
the syphilitic taint to the mother. Non-syphilitic pemphigus, the result 
of cachexia, sometimes appears soon after birth, but its primary and 
usual seat is around the neck and upon the body. I have known it to 
appear within the first week of life, and end fatally by the close of the 
second week. I have not found it difficult to distinguish it from syphi- 
litic pemphigus by the history of the family, and its absence from the 
palmar and plantar surfaces of the hands and feet. Condylomata, 
mucous patches, and stains of a copper color are the principal syphilitic 



CLINICAL HISTOEY. 179 

affections, besides pemphigus, which have been observed at birth on the 
bodies of contaminated infants. It is stated that M. Cullerier, in ten 
years' attendance at the Hopital de Lorraine, met only two cases of 
syphilitic manifestations at birth, and Victor de Meric only two cases in 
forty-six infants, who were affected with congenital syphilis (Bumstead) ; 
but in the practice of others a larger proportion have exhibited symp- 
toms at birth. Ordinarily the period in which congenital syphilis is 
first revealed by symptoms is between the fifteenth and fortieth days. 
Rarely the manifestation of the disease is delayed several months. M. 
Diday ascertained the time of the commencement of symptoms in 158 
cases as follows : 

Before the completion of one month after birth, in . .86 

Before the completion of two months after birth, in . .45 

Before the completion of three months after birth, in . . . 15 

At four months 

At five months .......... 

At six months .......... 

At eight months .......... 

At one year ........... 

At two years 

In cases of tardy commencement of syphilitic symptoms it is probable 
that the poison has. been partially eradicated from the affected parent by 
appropriate treatment. 

The nutrition of the infant who has inherited the syphilitic taint, but 
does not exhibit it at birth, is for a time good, but it begins to be im- 
paired when the local manifestations of syphilis appear, or soon after. 
The system gradually wastes ; the skin loses its fresh and healthy ap- 
pearance, and becomes sallow, and, after a time, more or less wrinkled ; 
the features become pinched and contracted, and wear a sad expression. 
M. Diday says: "Next to this look of little old men, so common in 
new-born children doomed to syphilis, the most characteristic sign is the 
color of the skin." Trousseau thus describes this discoloration of the 
surface: "Before the health becomes affected, the child has already a 
peculiar appearance; the skin, especially that of the face, loses its trans- 
parency ; it becomes dull, even when there is neither puflfiness nor 
emaciation ; its rosy color disappears, and is replaced by a sooty tint, 
which resembles that of Asiatics. It is yellow, or like coffee mixed with 
milk, or looks as if it had been exposed to smoke ; it has an empyreu- 
matic color, similar to that which exists on the fingers of persons who are 
in the habit of smoking cigarettes. It appears as if a layer of coloring 
had been laid on unequally ; it sometimes occupies the whole of the skin, 
but is more marked in certain favorite spots, as the forehead, eyebrows, 
chin, nose, eyelids — in short, the most prominent parts of the face ; the 
deeper parts, such as the internal angle of the orbit, the hollow of the 
cheek, and that which separates the lower lip from the chin, almost always 
remain free from it. Although the face is commonly the part most 
affected, the rest of the body always participates more or less in this tint. 
The infant becomes pale and wan." 

The infant whose system is profoundly affected by syphilis rarely 
smiles, and its voice is feeble and plaintive ; its frequent, whimpering cry 
is quite characteristic. 



180 SYPHILIS. 

Coryza is one of the earliest and most constant of the local affections 
in infantile syphilis. It is slight at first, attracting little attention on 
the part of the parents, who are not aware of its significance, and 
usually attribute it to a slight cold; but it gradually increases. It gives 
rise to a secretion from the Schneiderian membrane, at first thin, but 
which becomes more consistent, and is attended by the formation of 
scabs. The thickening of the mucous membrane, in consequence of the 
inflammation and the presence of crusts, narrows the passage through 
the nostrils so as to produce snuffling respiration, and sometimes render 
nursing difficult. In severe cases respiration through the nostrils is 
almost wholly prevented, so that death may occur from inanition, unless 
the breast be milked into the infant's mouth, or it be fed with a spoon ; 
but, ordinarily even in grave coryza, it continues to nurse, though obliged 
often to release its hold of the nipple to obtain breath. It is when coryza 
begins to interfere with lactation that it first alarms the parents. The 
inflammation at the same time may affect the throat and larynx, causing 
hoarseness of the voice. Ulceration of the Schneiderian membrane and 
the adjacent cartilage or bone is rare in infancy or childhood, although 
cases occur which are even attended with more or less flattening of the 
nose. Diday believes that the discharge which accompanies coryza is 
in great part due to mucous patches developed on the Schneiderian 
membrane. The upper lip, over which the discharge flows, becomes 
red, excoriated, and more or less incrusted. The coryza, in most cases, 
coexists with other local syphilitic affections. Occasionally it occurs 
alone, and is the only evidence of the presence of the specific taint, 
except such as is afforded by the malnutrition and general appearance 
of the patient. 

Mucous patches occur in most patients. They are developed either 
upon the mucous surfaces, or upon parts of the skin which are thin and 
exposed to friction, and such as are moistened by secretion or transuda- 
tion from the vessels underneath. The most common seat of mucous 
patches is at the termination of mucous canals ; but in infancy, on account 
of the peculiar delicacy of the skin, they may occur upon almost any 
part of the cutaneous surface. They are most common, however, around 
the anus, upon the vulva, scrotum, umbilicus, labial commissures, in the 
axillae, and behind the ears. 

Mucous patches upon the skin present a rounded border, and are 
slightly elevated. Their color has been compared to that of skin which 
has been softened by the prolonged application of a poultice. Erosions 
and cracks sometimes occur in the patches, from which a thin liquid 
exudes. 

Upon mucous surfaces they are less elevated than upon the skin, and 
are prone to ulcerate. These ulcerations, commencing at the centre, 
extend, and soon the mucous patch disappears, and its site is occupied 
by an ulcer. The ulcer may be circular, oval, elliptical, crescentic or 
irregular. The arches of the fauces are a common seat of mucous 
patches. 

Roseola is an occasional symptom of infantile syphilis. "It is dis- 
tinguished," says Diday, u by patches of a bright rose-color, circum- 
scribed, irregularly rounded, of various sizes (most frequently about as 



VISCERAL LESIOXS. 181 

large as one of the nails) ; appearing, by preference, on the belly, lower 
part of the chest, neck, and inner surface of the extremities." The 
spots do not readily and fully disappear by pressure. 

Pemphigus appearing soon after birth has already been alluded to. 
Its most frequent seat, whether occurring at birth or as a subsequent 
manifestation, is, as Ave have stated, the palms of the hands, soles of the 
feet, the fingers, and toes. This eruption commences by a violet tint 
of the skin, and in the course of twenty-four to forty-eight hours a 
watery fluid collects underneath, which soon becomes turbid. The skin 
peels off, and sometimes an angry sore results, which bleeds readily 
when rubbed or pressed. In other and more favorable cases new skin 
takes the place of that which is lost. Pemphigus at birth is a precursor 
of death, but when it appears for the first time some weeks after birth, 
it is a less unfavorable prognostic sign. In cases of recovery it disap- 
pears, with proper treatment, in two or three weeks. 

Acxe, Impetigo, and Ecthyma are occasionally observed in children 
afflicted with syphilis. The indurated pustules of acne occur most fre- 
quently upon the shoulders, back, chest, and buttocks. The pus is 
sometimes absorbed, and in other cases discharged, leaving a small 
cicatrix, which, after a time, disappears. Impetigo appears most fre- 
quently upon the face, and occasionally upon the chest, neck, axilla, and 
groin. Unlike simple impetigo, the syphilitic impetiginous eruption is 
surrounded by a copper-colored areola, Ecthyma occurs upon the legs 
aud buttocks chiefly. It commences as violet-colored spots, which are 
soon transformed into pustules. Ulcers succeed, which, in reduced states 
of the system, are apt to enlarge and endanger the safety of the child. 
Of the three pustular eruptions, acne, according to Diday, is the least 
serious — indicating a "less confirmed diathesis." Ecthyma is the most 
serious, on account of the reduced state of the system with which it is 
usually associated. Syphilitic papulae and squamae are rare in infants, 
but cases have been observed. Onychia occasionally occurs, though less 
frequently than in syphilis of the adult. 

Visceral Lesioxs.- — The visceral lesions which result from the 
syphilis of infancy and childhood are, suppuration in the thymus gland ; 
gummy tumors in certain organs, most frequently the lungs and liver ; 
increase of the connective tissue of the liver, known as syphilitic 
cirrhosis ; partial perihepatitis, with depressions resembling cicatrices on 
the surface of the liver: peritonitis; periostitis, with thickening of the 
bone and exostosis. 

Suppurative inflammation in the thymus gland is not common, or has 
not been frequently observed. When it is present the gland sometimes 
presents its normal appearance externally, and the abscess is only discov- 
ered by incisions. Gummy tumors are white and spheroidal ; some are 
as small or smaller than a pin's head, while others are as large as a pea, 
or even a hazel-nut. I have seen a considerable number of them not as 
large as a pin's head, in the liver of an infant. Gummy tumors, accord- 
ing to Lebert, consist "of loose fibrous tissue, made up of pale, elastic 
fibres," enclosing in their large interspaces a homogeneous granular sub- 
stance, the elements of which are less adherent to each other than in 
deposits of true tubercle." Lebert also, with other microscopists, dis- 



182 SYPHILIS. 

covered round granular cells in these tumors. According to Robin, 
gummy tumors " are made up of rounded nuclei belonging to fibro-plastic 
cells, or cytoblastions ; of a finely granular, semi-transparent, and amor- 
phous substance ; and, finally, of isolated fibres of cellular tissue, a small 
number of elastic fibres, and a few capillary bloodvessels." 

Constitutional syphilis is one of the principal causes of waxy degenera- 
tion, and the spleen and liver of infants may be enlarged from this cause. 
Dr. Samuel Gee has expressed the opinion that in half the cases of 
hereditary syphilis the spleen is enlarged. (London Lancet, April 13, 
1867.) 

Infiltration of the liver by fibrous substance was first noticed by Giib- 
ler. It is not common in the infant. A specimen, showing this lesion, 
was presented to the London Pathological Society in 1866, by Dr. 
Samuel Wilks. The following remarks by Dr. Wilks convey a good idea 
of the appearance and state of the liver in syphilitic cirrhosis : " Having 
dissected the bodies of several infants who have died of congenital syph- 
ilis, I have found fatty livers, and an inflammation of the capsule; but 
in only two have I discovered adventitious products of a fibrous character. 
The present example, however, corresponds in every particular with the 
disease described by Giibler. It must be distinguished (at least as far as 
the naked-eye appearance reaches) from syphilitic disease of adults, 
of which many specimens have been before the Society. In these the 
organ is cicatrized on the surface, and contains distinct nodules of 
fibrous tissue ; while in the disease of children, as in the present speci- 
men, the whole organ is infiltrated by a new material, and it conse- 
quently becomes, as described by Giibler, hypertrophied, globular, and 
hard, resistant to pressure, and even when torn by the fingers, its 
surface receives no indentation from them ; it is also elastic, and when cut, 
creaks slightly under the scalpel. This was the form of disease in the 
present specimen. It came from a syphilitic child, a month old, in 
whom the liver could be felt enlarged during life, and when removed 
weighed a pound and a half. It was smooth on the surface, and so 
hard that it resembled rather a fibrous tumor than a liver. It is seen 
that the liver in the syphilitic child is liable to three distinct patho- 
logical processes, namely, gummy tumors, cirrhosis or fibroid degenera- 
tion, and waxy degeneration." 

Syphilitic perihepatitis and periostitis are more' rare in infancy and 
childhood than in adult life, but they occasionally occur. The late Sir 
James Y. Simpson considered peritonitis in the foetus one of the results 
of syphilis, and a cause of its death. 

Osseous Lesions. — Within the last few years, important discoveries 
have been made in regard to the eifect of syphilis upon the nutrition of 
the bones in children. In 1870, Dr. Wegner, of Berlin, published his 
observations of the state of the skeleton in twelve syphilitic children, 
who were either stillborn, or who died within a few days or weeks after 
birth. He lound clear proof that the syphilitic dyscrasia very frequently 
disturbs the nutrition and produces anatomical changes in the skeleton 
of the fcetus. The following are the lesions, clearly referable to syphilis, 
which he observed : periostitis of long bones, including the ribs ; soften- 
ing, separation, and sometimes crepitation, at the point of union of dia- 



OSSEOUS LESIONS. 



183 



physis and epiphysis ; chalky concretions and infiltrations along the line 
of ossification ; fatty degeneration of marrow ; irregular formation and 
distribution of spongy substance in the epiphysis. These lesions were 
not all observed in each case, but they occurred with such frequency 
that there could be no doubt that they were due to the syphilitic taint 
of system. Confirmatory observations also, in twelve cases, have since 
been made by Waldeyer and Kobner. 1 

Again, there is a syphilitic lesion of the bone in children, which is 
not usually present or has not usually been observed at birth, but is 
developed in the first weeks or months of infancy. The lesion alluded 
to is a circumscribed enlargement of one or more bones. This has been 
most frequently observed upon the long bones, including the clavicle 
and ribs ; but in certain children it occurs upon other bones in addition. 
In some cases it is one of the first manifestations of hereditary syphilis, 
occurring even sooner than the coryza, while in others several months 
elapse before it appears. In one case, reported by Dr. Bulkley, 2 of this 
city, it was first seen only a few days after birth, being perhaps con- 
genital ; while in another case, in which the enlargement was upon 
certain phalanges, and which is represented in the accompanying figure, 
it appeared at the age of twelve months. When it occurs upon a pha- 
langeal bone, it is designated dactylitis syphilitica. 

Fig. 22. 




The enlargement, if upon a long bone, ordinarily begins at or near 
the point of union of the diaphysis with the epiphysis. It is located 
upon the extremity of the shaft which it encircles, and it extends over 



1 See elaborate paper by E. W. Taylor, M.D., New York Journal of Obstetrics, 
etc., July, 1874. 

2 Kare" Cases of Congenital Syphilis, New York Med. Journal, May, 1874. 



184 SYPHILIS. 

a part or nearly the whole of the epiphysis. It has an elevation of 
perhaps one-half or three-quarters of an incli in typical cases ; its surface 
is smooth, or slightly undulating, and the skin over it, though distended, 
has its normal appearance, and is easily movable, unless ulcerations have 
occurred. 

These enlargements, which result from the specific inflammation, 
occurring in the periosteum and the bone, may resolve under proper 
treatment ; but if neglected, and the antihygienic conditions are bad, 
degenerative changes may occur, ending in ulceration and destruction 
of the diseased part to a greater or less extent. 

Though these bone enlargements, whenever observed, should excite 
suspicions of syphilis as the cause, enlargements which present the 
same general appearance do occur from other causes. Such a case was 
observed by me in the children's class in the Outdoor Department of 
Bellevue, and Dr. Bulkley details another case in his paper. In the 
case observed by me, the inflammation and enlargement seemed to be 
strumous. Baumler says : " Dactylitis syphilitica does not always origi- 
nate in the bone ; similar appearances may be produced through gum- 
mous formation in the sheaths of the tendons, and in the fibrous structure 
of the finger ;" and again, "Its outward appearance may be produced 
also by tuberculosis, enchondroma, or sarcoma of the bone-marrow." 
(Art. Syphilis, Ziemsseris JEncycl.) 

Mr. J. Hutchinson, of London, has called attention to the fact that 
hereditary syphilis, having perhaps been manifested by the usual symp- 
toms during infancy, and then becoming 
latent, may give rise to new symptoms after 
the fourth year. The most noticeable of 
these symptoms is a dwarfing of the per- 
manent incisor teeth, which are rounded 
and peg-like, and their enamel notched at 
the free ends of the teeth. On account of 
the small size and shape of the teeth, there 
are interspaces between them. This abnor- 
mal development is most marked in the central incisors Of the upper 
jaw, and in certain cases it is limited to them, and it never appears in 
the other incisors unless it does also in them. Another symptom, which 
only appears in hereditary syphilis, is an interstitial' keratitis occurring 
on both sides, and attended by the deposition of fibrin in the substance 
of the cornea. In a few weeks the inflammation declines, but a slight 
opacity of the cornea remains. The cerebral nerves may become af- 
fected, usually a single pair — if the auditory, deafness resulting ; if the 
optic, dimness of sight. Occasionally there are other manifestations of 
syphilis in this period, as enlargement of spleen and liver, and nodes 
upon the long bones. 

Prognosis. — This depends in great part on the general condition of 
the patient. If there be much emaciation, and the symptoms indicate 
a deeply seated cachexia, a considerable proportion perish. On the 
other hand, if the general health be not greatly impaired, although the 
local affections are pretty severe, the prognosis with correct treatment 
is good. The younger the infant, when the symptoms of syphilis 
appear, the more unfavorable, as a rule, is the prognosis. 




TREATMENT 185 

Treatment. — Parents who beget syphilitic children ought, from a 
due regard for their offspring, to make use of antisyphilitic remedies, 
although they present in their persons no evidences of syphilitic taint. 
A good prescription for the parents is one-sixtieth of a grain of cor- 
rosive sublimate in the compound tincture of bark, given twice or three 
times daily for several weeks. If the father have had syphilis, both 
parents should be subjected to this treatment, and it may be continued, 
at least on the part of the mother, during the first months of her gesta- 
tion. So small a dose of the mercurial does not, in my opinion mate- 
rially increase the liability to miscarry. There is much more danger 
of miscarrying from allowing the syphilitic taint to remain uncontrolled. 
Some prefer the use of mercurial ointment in the treatment of pregnant 
women for syphilis, in the belief that it is less likely to produce abor- 
tion. It is used for this purpose in the proportion of one drachm to 
the ounce. It is equally effectual in the eradication of the syphilitic 
taint with the small dose of corrosive sublimate recommended above for 
internal administration ; but it is impossible to determine the quantity 
of mercury which enters the circulation when inunction is employed, 
and salivation is more likely to occur. 

Syphilis in the infant requires mercurial treatment as in the adult. 
Mercury may be employed internally or by inunction. Some prefer 
inunction in the treatment of ordinary cases in the manner recom- 
mended by Sir Benjamin Brodie. I have spread," says he, " mercurial 
ointment, made in the proportion of a drachm to an ounce, over a flannel 
roller, and bound it round the child once a day. The child kicks about, 
and, the cuticle being thin, the mercury is absorbed. It does not either 
gripe or purge, nor does it make the gum sore, but it cures the disease. 
I have adopted this practice in a great many cases, with the most signal 
success." Trousseau, on the other hand, discountenances the use of 
inunction, as mercurial ointment applied to the skin produces irritation, 
and increases the suffering and restlessness of the child. He prefers 
the following solution, which is known as Van Swieten's, for internal 
treatment : 

R . — Hydrarg. bichlorid .1 part. 

Aquae ........ 960 parts. 

Spts. rectific. 100 parts. — Misce. 

Dose. — One, or at most two grammes (15.434 to 30.868 grains), in milk, daily. 

In order to avoid the risk of establishing a diarrhoea, and to leave 
the stomach free for the employment of other medicines, as cod-liver oil 
and the iodide of iron, I prefer and commonly prescribe for infants in- 
unction with the mercurial ointment diluted with eight times its quan- 
tity of lard, cold cream, or vaseline. It should not be applied as a 
plaster, but a quantity of the size of a large chestnut should be rubbed 
three times daily upon the neck or breast of an infant of three or four 
months. For children over the age of eight or ten months, Van 
Swieten's, or one of the following formulae may be employed : 

R. — Hydrarg. cum creta .... . gr. ifj— vj. 

Sacch. alb. . . . . . . . £)j. — Misce. 

Divid. in chart. No. xii. One powder three times daily. 



186 SYPHILIS. 

R. — Hydrarg. chlor. corros gr. ss-j. 

Syr. sarsae comp. ...... 5ij. 

Aquie oviij. — Miscc. 

Dose. — One teaspoonful three times daily. 

R. — Hyd. chlor. corros gr. ss. 

Potas. iodid 3j. 

Ferri et ammon. citrat. . . : . • 3J- 

Syr. simplic gvj. — Misce. 

Dose. — One teaspoonful three times daily for a child of 3 to 5 years. 

R. — Hyd. chlor. corros. ...... gr. j. 

Potas. iodid , jjj. 

Syrup, simplic. j 

Aquae aa ^ij. — Misce. 

Dose. — Six drops three times daily for a child of 3 months. 

Mercury, in whatever way employed, should not be discontinued 
entirely till several weeks after the syphilitic symptoms have disap- 
peared ; it is proper to continue it for a time, in diminished quantity 
and fewer doses, after the health seems fully restored. 

When the mercurial is omitted, tonics are often required. The pre- 
parations of cinchona are useful in certain cases, as are also those of 
iron. If the patient remain feeble and pallid, presenting evidences of 
struma, cod-liver oil and syrup of the iodide of iron will be found 
beneficial continued for some weeks or months after the mercury is 
discontinued. Attention should always be given to cleanliness and the 
hygienic management of the patient. In some instances direct treat- 
ment of the local affections is serviceable. To aid in the cure of 
syphilitic coryza, the following ointment should be applied within the 
nostrils by a nasal sponge three times daily : 

R. — Ung. hydrarg. nitratis ..... ^ij 

Ung. zinci oxidi ...... ^ij. — Misce. 

Recently I have been in the habit of employing Squibb 's oleate of 
mercury, two per cent., for syphilitic coryza of infants, and the effect 
has been satisfactory. It may also be employed by cutaneous inunction 
in the treatment of the general disease. 

Condylomata or mucous patches seated upon the. cutaneous surface 
should be dusted with calomel. At my clinique, in April, 1871, a child 
two years and ten months old was presented, with a large condylo- 
matous outgrowth near the anus. The history of the child showed that 
in all probability the disease had been contracted within a year from 
syphilitic children in one of the public institutions. Within three 
weeks this affection disappeared by dusting upon it calomel once daily, 
with appropriate internal treatment. 

An infant under the age of twelve months should have breast-milk, 
and if it present symptoms of syphilis, and the mother who suckles it 
or the wet-nurse have none, she should be warned of the danger, and 
should watch for any abrasion upon her nipples. If an abrasion occur 
through which her system might be infected, or even without an abrasion, 
it will be safer to wash the nipples after each nursing with a mild solution 



TREATMENT. 187 

of corrosive sublimate. The infant should be kept clean by bathing it 
in tepid water twice daily, and excoriations upon its lips or mucous 
patches should be bathed before the nursing with some mild disinfectant 
solution, as boracic acid. The best possible hygienic conditions should 
be provided for the infant, since cachexia is commonly present. It 
should be taken out-door frequently in suitable weather, and its removal 
from the city to the country, especially in hot weather, may be advis- 
able. If the mother be syphilitic, her milk may be too thin and 
deficient in nutritive properties, and if so, its use should be supple- 
mented by artificial feeding, or a wet-nurse should be procured. The 
cachexia which remains after the disappearance of the syphilitic mani- 
festations requires the use of tonics, as cod-liver oil and syrup of the 
iodide of iron. 

Syphilitic symptoms may reappear during childhood. The exan- 
themata rarely appear at this age when the proper treatment has been 
employed in infancy, but condylomata and gummy tumors may, and 
they require a return to the mercurial treatment. If the bones are 
affected, the iodide of potassium is the proper remedy. It causes 
manifest improvement in the disappearance of the periosteal pains and 
swelling. 



SECTION II. 

ERUPTIVE FEVERS. 



CHAPTEE I. 

MEASLES. 

The disease known in the vernacular as measles has also the names 
rubeola and morbilli. It is a common exanthematic affection, occurring 
at any age, but most frequently in childhood. It affects once the 
majority of mankind. Writers recognize three stages of measles : 
first, that of invasion, which ends with the appearance of the eruption; 
secondly, the eruptive stage ; and, thirdly, the stage of decline or des- 
quamation. 

Etiology. — Micrococci have been found in the blood of rubeolar 
patients by Coze and Feltz. Keating also discovered them during an 
epidemic of malignant measles {Phila. Med. Times, Aug. 12, 1882), 
and Ransome, Braidwood, and Vacher found them in the breath of 
patients, as well as in their tissues {Brit. Med. *Journ., Jan. 21, 
1882). It seems probable that they are the specific principle; if so. 
they remain dormant in the system about twelve clays, which is the 
incubative period. 

Symptoms. — This disease commences with such symptoms as usually 
occur in mild but pretty general inflammation of the air-passages, 
namely, cough, fever, anorexia, and thirst. The eyes present a suf- 
fused, moderately injected, and brilliant appearance, and the buccal and 
faucial surfaces are injected. The Schneiclerian membrane, and that 
lining the larynx, trachea, and bronchial tubes, participate in the 
increased vascularity. The cough at first is dry, and sometimes dis- 
tinctly croupy. Catarrhal or false croup, indeed, is not infrequent in 
the initial period of measles. The cough is attended by slight accelera- 
tion of respiration, and by little or no pain in the respiratory move- 
ments. If auscultation be practised at this early stage, we observe the 
vesicular murmur, somewhat harsh in character, and sometimes sonorous 
and sibilant rales. A little later, rales of a moist character appear. 

The patient, if old enough, commonly complains of headache, and of 
dull pain in the epigastric region, or the centre of the sternum, due to 
the bronchitis. With these local symptoms febrile reaction occurs. 
The temperature rises to about 102° or 103°, as indicated by the 
thermometer in the axilla. The pulse .numbers from 110 to 130 per 
minute. The febrile movement is greater than in primary tracheo-bron- 
(188) 



SYMPTOMS. 189 

chitis, except when the bronchitis extends to the bronchioles, but it is 
less than in most cases of scarlet fever. 

The fever in the premonitory stage of measles after the first day is 
not uniform. It is attended by remissions and exacerbations, the former 
occurring in the first part of the day, the latter in the evening. Some- 
times two exacerbations occur in the day. The face is flushed and 
somewhat swollen, especially during the times of increase in the fever, 
and the child is clrowsy or restless. Vomiting, so common a symptom 
in the commencement of scarlet fever, occasionally occurs in measles. 
While in scarlet fever this takes place in the first twenty-four hours, in 
measles it takes place with about equal frequency at any period pre- 
viously to the eruption. It was present during the first stage, sometimes 
almost as late as the eruptive period, in thirteen, and was absent in 
twenty-three cases, in which I preserved records in reference to this 
symptom. 

The duration of the first stage varies in different cases. It is usually 
from two to five days, with an average of about four. Occasionally it 
is more protracted on account of some disturbance in the economy, 
either from exposure to cold or other cause, which prevents the necessary 
afflux of blood toward the surface, and retards the eruption. In eighteen 
cases in my practice in which the duration of the cough previously to 
the appearance of the rash was accurately ascertained, the time varied 
from one to five days, with an average of three and one-third; in ten 
other cases it had continued, the parents stated, about a week, and in 
five, from one to two weeks, previously to the eruption. 

The eruption commences, when the disease pursues its normal course, 
upon the forehead and neck, then the face, and gradually extends down- 
ward, occupying from twenty-four to thirty-six hours in passing over 
the trunk and limbs. It appears first as indistinct red points, not more 
than a line in diameter, which increase in size and become more distinct. 
Their borders are uneven or irregular, or they are finely notched ; their 
general shape is, however, circular, except as two or more unite, when 
they may assume any form. The crescentic form which writers describe 
is due to the union of two points of eruption. The largest of these 
spots, when there is no coalescence, do not exceed a quarter of an inch 
in diameter, and many are much smaller. Frequently in plethoric 
children, if there be much fever, there is continuous redness over 
several inches of surface. The eruption is then confluent. This form 
is often observed upon parts of the surface where the capillary circula- 
tion is most active, when it is discrete elsewhere. In some of these 
cases, diagnosis of measles from scarlet fever is attended with difficulty. 

The rubeolous eruption is slightly elevated, the elevation not being 
appreciable to the sight, but it can be ascertained by passing the finger 
over the skin, when roughness is felt at the point of eruption. Some- 
times the elevation, especially in the commencement of the efflorescence, 
is not appreciable, even to the touch. The eruption is broad and flat, 
never acuminate, never changing its form to the vesicular or pustular. 
It disappears by pressure, and immediately reappears when the pressure 
is removed. It has been compared in appearance to flea-bites. Small, 
pointed, papular, vesicular, or pustular eruptions are sometimes seen in 



190 MEASLES. 

connection with those of measles, but they are accidental, occurring in 
other states of system, as well as in measles, if there be the same 
augmented temperature. 

In the commencement of the eruptive period the severity of the con- 
stitutional and local symptoms increases. The pulse and temperature 
correspond with the character which they presented during the exacer- 
bations of the first stage. The features are slightly swollen ; the eyes 
still watery and sensitive to light; the conjunctiva, ocular and palpebral, 
and the mucous membrane of the cavity of the mouth and of the air- 
passages, continue injected. The tongue is covered with a moist thin 
fur, and its papillae are prominent, though less so than in scarlet fever. 
The cough continues frequent, and is seldom attended with much 
expectoration, in uncomplicated cases; often there is no expectoration 
whatever. The appetite is lost, but drinks are readily taken on account 
of the thirst. Diarrhoea sometimes occurs on the first day of the erup- 
tion, but it lasts only a few hours, and, if the disease pursue its usual 
course, abates of itself. With the exception of this the bowels are 
regular, or a little constipated during the eruptive period. 

On the second day of the eruption, or sixth of the fever, the symp- 
toms begin to abate. The pulse is less accelerated, and the temperature 
diminishes ; the cough is less frequent and is easier, and the flushed 
and swollen appearance of the face declines. By the close of the third 
or on the fourth day the rash has disappeared in the order in which it 
extended over the body. There only remain faint maculae, which in 
the course of a day or two fade completely. 

With the disappearance of the rash the fever nearly or quite ceases, 
but a slight and painless cough continues for several days. 

Occasionally the eruption presents a livid appearance; this is tne 
rubeola nigra of writers. From cases which I have observed, it is my 
opinion that this should not be considered a distinct species in the vast 
majority of patients, but that the dark color is due to internal inflam- 
mation, usually capillary bronchitis or pneumonia, which prevents full 
decarbonization of the blood. Rarely rubeola nigra is due to the 
vitiated state of the blood, or the malignant nature of the disease. 
The course of the eruption in this form of measles is somewhat dif- 
ferent; it continues longer, fades more slowly, and does not disappear 
so readily on pressure. Traces of it are observed a week or more after 
its first appearance ; it is likely to be fatal. Measles may present this 
form from the beginning, or, commencing as vulgaris, it may pass into 
rubeola nigra. 

Measles may be irregular in form, but aberrations are less frequent 
than in scarlet fever. Writers describe measles without catarrh, and, 
on the other hand, with catarrh but without the rash. But positive 
diagnosis in such cases must be difficult. It is probable that simple 
catarrh and roseola have sometimes been mistaken for the two forms of 
irregularity mentioned; but when a child, in a family of children affected 
with measles, presents all the symptoms of that disease, except the 
catarrh or except the eruption, the diagnosis of irregular measles would, 
as a rule, be correct. 

Occasionally the stage of invasion is very short, or even absent. In 



COMPLICATIONS. 191 

one case the parents informed me that the catarrhal symptoms began on 
the day when the eruption appeared. Convulsions sometimes occur at 
the commencement of measles, as well as during its progress. A single 
convulsive attack at the commencement of measles is usually not dan- 
gerous ; when repeated, it is more serious ; it is also more serious when 
it occurs in the course of measles. In certain patients the eruption ap- 
pears in an irregular and partial manner, occurring perhaps, at a late 
period, and indistinctly, upon the trunk alone, or upon the trunk and 
partially upon the legs. In many cases of deferred or partial eruption 
there is internal congestion or inflammation of some part, which causes 
withdrawal of blood from the surface, and thus prevents the normal 
development of the rash. 

When the eruption disappears the third stage commences, that of des- 
quamation. It is characterized by a scanty furfuraceous exfoliation of 
the epidermis. The desquamation is seldom as great as in scarlet fever, 
and it occurs most where the eruption has been thickest and the epider- 
mis most inflamed. Exfoliation occurs between the fourth and seventh 
days after the commencement of the eruption, the eighth and the 
eleventh of the disease. Frequently it does not take place, or is so slight 
as not to be observed. 

With the disappearance of the rash, the symptoms rapidly abate. The 
pulse becomes more natural, the temperature is reduced, the digestive 
organs return to their normal state, and the convalescence is established. 
The cough continues several days after the other symptoms abate, but 
it is less and less frequent, and is not painful. 

Complications. — The complications of this disease are important. 
Much of the success of the physician in the management of measles de- 
pends upon a correct diagnosis and understanding of them. The most 
frequent of these complications are bronchitis and broncho-pneumonia. 
Slight bronchitis is uniformly present in measles, but if it increase so 
as to cause embarrassment of respiration, and become a scource of dan- 
ger, it is properly a complication. This complication, as well as pneu- 
monia, may occur at any period of measles; but it commences most 
frequently in the first stage. Occurring in the first stage, it may pre- 
vent the regular appearance of the rash ; if in the second, it often causes 
retrocession of it. 

When bronchitis becomes really serious, it usually has invaded the 
minute bronchial tubes. This disease, designated capillary bronchitis 
or suffocative catarrh, I have elsewhere described. The clinical history 
of fatal bronchitis, as a complication of measles, is as follows : The re- 
spiration, at first not notably altered, becomes by degrees, accelerated, 
and the patient more and more fretful. The pulse, instead of becoming 
less accelerated, as after the first days of simple measles, is daily 
more rapid, and the respiration more frequent and labored. The dysp- 
noea gradually increases, the inframammary region is depressed, during 
each inspiration, and the subcrepitant rale is heard on both sides of 
the chest. There is, probably, collapse or inflammation of some of 
the lobules. Finally the prolabia and fingers become livid, and death 
occurs from apnoea. Capillary bronchitis is diagnosticated from pneu- 
monitis by the physical signs. It is in the young child more dan- 



192 MEASLES. 

gerous than that disease, unless perchance the latter be double. A 
large proportion of those affected under the age of three years, die. The 
anatomical characters of fatal bronchitis occurring in connection with 
measles, I have had an opportunity to inspect. In an infant who died 
with this complication in the Infants' Hospital in the spring of 1867, 
there were evidences of continuous inflammation from the epiglottis to 
the minutest bronchial tubes. 

Pneumonia as a complication does not differ materially from the idio- 
pathic inflammation, except that it is more protracted and fatal. Its 
form is in most cases catarrhal, resulting from an extension downward 
of the bronchitis. 

The next most frequent serious complication of measles is entero- 
colitis. This may commence at any period during the course of the 
disease. If the colon be more especially the seat of inflammation, the 
evacuations contain mucus and blood, unless in young children, in whom 
the stools, even in severe colitis, commonly have a green color. The 
anatomical character of this complication varies in different cases, like 
the idiopathic form of inflammation. Sometimes there is simple arbo- 
rescence of the intestinal mucous membrane, with tumefaction of its 
follicles; in other cases, in addition to increased vascularity, the mucous 
coat is softened and thickened; and in others still, especially if the in- 
flammatory action have been protracted, ulceration occurs, for the most 
part, in the site of the solitary glands. Exceptionally, in fatal cases of 
measles attended with diarrhoea, no vascularity is observed after death, 
although the intestine may be thickened and softened. In such cases 
the diarrhoea was probably inflammatory, the injection of the vessels 
having disappeared after death. 

Severe and obstinate diarrhoeal affections occurring with measles, 
usually commence as the primary disease is about declining. They 
then become sequelae, ending fatally in many instances, especially in 
the summer months, several days or perhaps weeks after the disappear- 
ance of the eruption. Diarrhoeal attacks, occurring in, or previously 
to, the eruptive stage, are, as a rule, mild and easily relieved. 

In some grave cases, measles have a tendency from the first to affect 
the internal organs more than the surface. There can coexist bron- 
chitis, pneumonia, and entero-colitis, with indistinctness of the eruption 
on the skin. Such complications render a fatal result highly probable. 

Eclampsia is also an occasional very dangerous complication. It 
sometimes occurs very suddenly and unexpectedly. A child of five 
years in my practice, apparently progressing favorably with measles, 
was allowed to sit at dinner with the family, suddenly and without 
premonition, eclampsia occurred, the rash receded, and notwithstanding 
vigorous treatment death resulted in a few hours. Rapidly developed 
cerebral congestion seemed to be present. To prevent such a compli- 
cation, the patient should remain quiet in bed during the eruptive 
stage. 

Another very fatal complication and sequel is true croup, commenc- 
ing when rubeola is beginning to decline ; but it is less frequent than 
pneumonia or entero-colitis. In catarrhal or false croup, which, as has 
been previously stated, is not infrequent at the commencement of measles, 



ANATOMICAL CHARACTERS. 193 

the cough has a loud, ringing character. In true croup, on the other 
hand, it is hoarse or harsh, and less distinct, on account of the presence 
of the pseudo-membrane in the larynx. True croup, always a grave 
disease, is more serious when it occurs as a complication of measles than 
in the idiopathic form, not only because the blood is vitiated and the 
system reduced by the primary affection, but because the inflammation 
of the mucous surface is in general more extensive, as is also, I believe, 
the pseudo-membrane. This membrane in the croup of measles I have 
seen extend so far down the air-passages, that tracheotomy could not 
have been attended by any decided amelioration of symptoms. This 
complication, though always grave, is not, however, necessarily fatal. 
I have known cases recover by inhalation of spray, when for days there 
had been dyspnoea and other evidences of a pretty firm pseudo-mem- 
brane. True croup causes continuation of the fever, which had perhaps 
beinin to abate. 

Diphtheria, when epidemic, also frequently complicates measles. 
Much of the mortality from measles in this city, since the year 1858, 
was due to this cause. In cases observed by myself, diphtheria usually 
began while the fauces were still inflamed, and sometimes before the 
eruption had begun to fade. The pseudo-membranous laryngitis or 
true croup mentioned above, is, in most instances, in localities where 
diphtheria prevails, a local manifestation of this disease. 

These are the most common complications of measles. There are 
others of less frequent occurrence, among which may be mentioned 
stomatitis, pharyngitis, and otitis sufficiently severe to be considered 
complications. Rarely, also, purpura, attended by hemorrhages from 
the different mucous surfaces, occurs in connection with measles. 
This complication is, however, more frequent in certain other con- 
stitutional diseases, as scarlet fever, and especially variola. 

It is seen that the inflammations which are apt to occur in the course 
of measles are chiefly of the mucous surfaces. In scarlet fever, on the 
other hand, the inflammations are more frequently of serous surfaces. 

There are other affections, originating in measles, which are rather 
sequelae than complications. Gangrene of the mouth is one which, as 
stated in another part of this book, is more apt to occur after measles 
than any other disease. After a severe epidemic of measles in the New 
York Foundling Asylum, in 1874, three cases of gangrenous vulvitis 
occurred in those who had been affected. Ophthalmia commencing in 
measles often persists for weeks or months. It may give rise to granu- 
lation of the lids, and cases have been reported of violent inflammation 
of a purulent character, producing ulceration of the cornea, and 
destroying vision. The ophthalmia is sometimes very intractable. 
Inflammation of the Schneiderian membrane, commonly present during 
measles, often continues as a sequel, extending back as far as the 
Eustachian tube, where it may cause swelling, with impairment of 
hearing, and forward to the lip, where it may produce chronic eczema. 

Anatomical Characters. — I have made, or witnessed, mainly 
in institutions, several post-mortem examinations of those- who have 
died in, or immediately after, an attack of measles. In all there were 
lesions due to complications. Indeed, death directly from measles is so 

13 



194 MEASLES. 

rare that few have had an opportunity of studying the anatomical 
characters apart from the complications. In those who have died 
without any obvious coexisting disease, and these cases chiefly occur in 
the malignant form, there has been congestion of the internal organs, 
especially marked in the lungs, and sometimes the tissues appeared 
softened. The blood, also, in the malignant form, has a darker hue 
than natural, and ecchymotic patches have been observed upon the 
mucous surfaces and elsewhere, corresponding in character with the 
petechia under the skin which sometimes occur in this form of measles. 
In cases resulting fatally from bronchitis or pneumonia, the bronchial 
glands are commonly tumefied in the same manner as the mesenteric 
glands are enlarged in enteritis, and the glands of the mesocolon in 
dysentery. 

Nature. — Rubeola, like the other exanthematic fevers, is due to a 
materies morbi, probably micrococci, as has been stated above. It is 
highly contagious through the air. It has been inoculated by the serum 
from vesicles which sometimes occur in connection with the rubeolous 
eruption, and also by the blood from a patient. Inoculation does not 
appear to moderate the disease, and as measles, when contracted in the 
ordinary way, is not in itself dangerous, but dangerous only from com- 
plications, inoculation is not performed, except as a matter of scientific 
interest. The usual mode of propagation is through the air. It is com- 
municated both by the breath and clothing. By fomites the virus is 
sometimes conveyed a long distance. Under whatever circumstances 
measles may occur, probably the specific principle has been communi- 
cated from some infected person. AVe frequently meet cases, as one in 
a sparsely settled district that has come to my knowledge in which 
exposure cannot be traced. Yet the immunity of certain islands for 
centuries, till infected through commerce, renders the doctrine of an 
origin de novo improbable. 

Twelve to fourteen days elapse from the time of infection to the com- 
mencement of the eruption. In cases observed in the children's depart- 
ment of Charity Hospital, the incubative period was ascertained to be 
about twelve days. In those who have been inoculated, this period is 
said to have been about one week. Rubeola prevails epidemically, like 
the whole class of infectious diseases, and in different epidemics the 
type may vary as well as the character of the complications. 

Diagnosis. — The diagnosis of measles, previously to the eruption, is 
often difficult. The catarrhal symptoms then predominate, and these are 
such as may occur independently of any constitutional or blood disease. 
The first stage, therefore, is not infrequently mistaken for coryza, or 
mild bronchitis. The points of differential diagnosis are the suffused 
appearance of the eyes, the greater degree of fever on the first clay than 
would be likely to arise from so moderate an amount of local disease, 
and morning remission and evening exacerbation of the fever. Measles 
in the first stage has been mistaken for remittent fever. The catarrhal 
symptoms should prevent such an error. 

Sometimes roseola closely resembles measles in appearance, but the rash 
of roseola appears within a few hours after the commencement of febrile 
symptoms, and almost simultaneously over the whole body, and without 



TREATMENT. 195 

those local symptoms referable to the mucous surfaces, which characterize 
measles. 

Variola on the first day of the eruption has sometimes been diagnosti- 
cated measles. I recollect once being called to an infant with fatal 
confluent smallpox, who was said to have measles. A physician, a few 
days previously, observing the red points in the commencement of the 
eruption, had made this absurd diagnosis, and, predicting a favorable 
result, had not thought it necessary to repeat his visit. In case of doubt, 
it is the part of prudence to defer making a positive diagnosis. A few 
hours suffice to show the distinctive characters of rubeolous and variolous 
eruptions. But the anxiety of friends often necessitates the expression 
of opinion. The absence or lightness of catarrhal symptoms, the earlier 
appearance of the eruption, and its papular feel under the finger in small- 
pox, enable us to discriminate between the two diseases in the commence- 
ment of the eruptive stage. Moreover, the symptoms in the initial periods 
are different, as will be seen in our description of smallpox. 

Prognosis. — This is favorable, provided that no serious complication 
arises. With internal inflammatory complication, on the other hand, 
the disease becomes much more grave. A large proportion thus affected 
die. The prognosis is less favorable in feeble children with scanty 
eruption, or an eruption appearing at a late period and irregularly. Dysp- 
noea, persistent and great acceleration of pulse, and coma, indicate an 
unfavorable ending. Convulsions occur much more rarely in the course 
of measles than in scarlet fever, and when they occur after the initial 
period they usually end in coma and death. 

Treatment. — Uncomplicated rubeola requires little medicinal treat- 
ment except to palliate symptoms. The child should be kept in an airy 
apartment, at a uniform temperature of about 70°. A temperature so 
elevated as to be uncomfortable to the nurse is injurious to the patient. 
But while the popular idea is erroneous, that he should be kept in a heated 
atmosphere, it is correct that currents of air and sudden reduction of 
temperature are dangerous. A violent and fatal attack of croup occurred 
in my practice in a girl of fifteen, in consequence of exposure at an open 
window at the close of the eruptive stage. The diet should be mild, and 
for the most part liquid. The patient, indeed, refuses solid food, but, 
on account of the thirst, takes liquids more readily. Farinaceous sub- 
stances, with milk, afford sufficient nutriment in ordinary cases. If the 
previous health have been poor and the vital powers reduced, or if there 
be a complication, more sustaining diet is required. Stimulation by wine 
or brandy is needed in these cases. During the two or three weeks suc- 
ceeding an attack of measles, care should be taken to avoid exposure to 
cold, or changes of temperature, since during this period there is great 
liability to inflammations of the mucous surfaces. 

The cough ordinarily requires treatment, inasmuch as the suffering of 
the child and loss of sleep are largely due to this symptom. Demulcent 
drinks, as flaxseed tea, infusion of slippery-elmbark, or solution of gum 
Arabic, are useful, to which, to render them more palatable, lemon-juice 
may be added. A small Dover's powder, or the mistura glycyrrhizse 
composita of the pharmacopoeia, given occasionally, relieves the severity 
and diminishes the frequency of the cough. 



196 MEASLES. 

As the cliief danger in measles is from inflammation of the respiratory 
organs, local treatment directed to the chest is important. The chest 
should be covered with oil silk, unless in the mildest cases. This in- 
creases the amount of eruption upon the surface underneath, and, I 
believe, tends greatly to prevent complication by bronchitis and pneu- 
monia. If the eruption be tardy in its appearance, or indistinct, it is 
well to produce moderate counter-irritation by some gentle irritant 
underneath, as camphorated oil, to which one-fourth part of turpentine 
is added. 

Affections which complicate measles should receive, for the most part, 
such treatment as is appropriate for them when idiopathic. Secondary 
diseases, however, require sustaining measures more than primary. In 
bronchial and pulmonary inflammations, which, if they occur early in 
measles, prevent the regular appearance of the eruption, or, if in the 
eruptive stage, cause its disappearance, prompt counter-irritation over the 
chest by sinapisms or otherwise is required. Trousseau states that he 
has derived benefit, in these cases, from what he designates urtication. 
This is produced by stroking the chest two or three times daily with the 
nettle (urtica dioica or urtica urens). This causes a prompt and abundant 
eruption, and with a less amount of suffering than one would suppose. 
The fever abates, and the respiration becomes more natural in proportion 
to the amount of nettlerash. On the second day the effect is less than on 
the first, and after three or four days, says Trousseau, no further irrita- 
tion results from the nettle. When counter-irritation is produced, by 
whatever method, the chest should be covered with a warm and soft 
poultice, as the ground flaxseed ; derivatives to the extremities are useful 
in such cases. In capillary bronchitis and pneumonia stimulating ex- 
pectorants are required, as carbonate of ammonium. The following I 
employ for a child of two or three years. 

R. — Tinct. ipecac, comp. (Squibb's liq. Dover's pulv.) gtt. viij-xvj . 

Ammon. carbonat gr. xvj-gss. 

Syr. bal. tolut. 

Aquas ........ aa ^j. — Misce. 

Dose. — One teaspoonful every two or three hours. 

Muriate of ammonium is also a good remedy in these cases, employed 
in double the dose of the carbonate. 

Quinia to reduce the fever, and digitalis as a heart tonic, are also very 
useful in these inflammations, given alone or alternately with the above. 

The cases of gangrenous vulvitis alluded to above were treated with 
a flaxseed poultice, and iodoform dusted over the surface each day or 
second day, with a satisfactory result. As regards the treatment of 
other complications, the appropriate measures are detailed elsewhere. 



ETIOLOGY. 197 



CHAPTEE II. 

SCAKLET EEVEK. 

It is supposed by some who have studied the history of scarlet fever, 
that it is a disease of ancient origin, but the descriptions of diseases left 
us by the old writers, and by those in the Christian era until after 
the middle ages, are so obscure, or differ so widely in the statements 
made from the symptoms of scarlet fever, that the impartial critic fails 
to find any clear evidence of its occurrence prior to the last four or five 
centuries. 

The first clear and undoubted portrayal of this disease in found in 
the medical literature of the sixteenth century. Sydenham and his con- 
temporaries in the seventeenth century witnessed epidemics of it, studied 
its nature more thoroughly, and consequently acquired a more accurate 
knowledge of it than that possessed by their predecessors. It was in 
this century that measles and scarlet fever were differentiated. During 
the last two hundred years scarlatina has been the subject of monographs 
too numerous to mention. It has long been regarded as one of the 
most important maladies of childhood, on account of its frequency and 
the great mortality that attends it, so that numerous cases and many 
epidemics are every year related in the medical journals. By this vast 
accumulation of observations and the patient and thorough use of the 
microscope our knowledge of scarlet fever has become full and accurate. 

As with most of the infectious maladies, scarlet fever extended to the 
Western World through European shipping. It was brought to North 
America about the year 1735. Tardily it spread to South America, 
where it appeared in 1829, and more recently it has been established in 
Australia. It entered Iceland in 1827, and Greenland in 1847. 

Etiology. — The evidence is strong that scarlet fever does not originate 
de novo — that it does not spring from certain atmospheric or telluric con- 
ditions, but is produced by a definite specific principle, since countries 
have been free from it for centuries till it was imported by commerce. 
That it appears in certain localities without any known exposure is 
attributed to the fact that the poison is so subtle and transmissible that 
it is conveyed long distances in articles of merchandise, even in small 
packages, so that those who chance to open them or come in contact 
with them are infected. It is believed that reading matter transmitted 
through the mails has in many instances been the medium of infection. 

The theory that the acute infectious maladies are caused by micro- 
organisms, or, as they are now designated, microbes, commonly dis- 
carded at first and believed to be chimerical, is rapidly gaining ground 
in the profession, and appears to be fully established as regards certain 
of them. These parasites, barely visible under high powers of the 
microscope, and ascertained to be vegetable by their behavior under 
certain chemical agents, exist in immense numbers in the blood, tissues, 



198 SCARLET FEVER. 

and secretions of patients suffering from the infectious maladies, espe- 
cially in the graver cases of them ; and the microscope shows that 
these organisms vary in shape and appearance so as to admit of 
classification. 

The germ theory has now become so important that it cannot be 
ignored in a monograph relating to so important an infectious malady 
as scarlet fever. The relation of microbes to the infectious diseases has 
been made the subject of investigation by Pasteur, Toussaint, and 
others in France, and by many in Germany, with most interesting 
results. The belief held by many, and which seemed very plausible, 
was that the microbes, instead of sustaining a causative relation to the 
maladies in which they occur, were the result of these maladies — that 
they sprang into existence in consequence of the vitiated state of the 
blood and tissues, just as fungi appear on decaying substances or as the 
oiclium albicans appears in certain morbid condition of the buccal sur- 
face and secretions. Obviously, in order to elucidate this matter and 
determine the relation of these parasites to the diseases in which they 
occur, it was necessary to experiment on animals, but, unfortunately, as 
a bar to successful experimentation many of the most important infec- 
tious maladies which afflict the human race, as typhus and typhoid 
fevers, the marsh fevers, and syphilis, do not occur in animals, or they 
occur in a changed and mitigated form. Others, however, can be pro- 
duced in their typical character in animals, as diphtheria, and others 
still originate in animals and are transmitted from them to man, as 
anthrax or splenic fever of the herbivora, and hydrophobia. Very in- 
teresting and important results have been produced by experimental 
researches with the microbes of certain of these diseases, which, if 
applicable to the common and fatal infectious maladies of an analogous 
nature in man, may yet result in immense benefit in mitigating the 
virulence of those affections which are the scourge of childhood, and 
which sensibly diminish the increase of population. It has been found 
possible to cultivate the microbes contained in the blood, tissues, and 
secretions in certain of the infectious diseases, and after a series of culti- 
vations, so that these organisms are far removed from the animal sub- 
stance which contained them, and with which they were so intimately 
associated in the individual, they have been employed for inoculation — 
with this important result, that the primary disease was reproduced. 
This seems to indicate beyond question the causative relation of these 
parasites to the diseases in which they occur. Experiments with the 
result which I have stated have been made with the microbes of splenic 
fever, chicken cholera, murrain, and certain other maladies. 

Pasteur employs as the media for cultivation — (1) urine neutralized 
by a few drops of potash solution; (2) a liquid prepared by boiling for 
twenty or thirty minutes the yeast of beer in water, neutralizing and 
filtering ; and (3), chicken tea, prepared by boiling equal parts of water 
and the lean of muscles a quarter of an hour, filtering and neutralizing. 
A small drop of infected blood is placed in the liquid of cultivation, and 
the microbes which it contains multiply so abundantly that the liquid 
becomes turbid in a short time, and they are found in all parts of it. 
A drop of this liquid is added to another portion of the medium, and 



ETIOLOGY. 199 

this also soon becomes turbid from the immense development of organ- 
isms which have the same microscopic appearance and character as 
those in the drop of blood. The process is repeated many times, until 
the microbes are far removed from their original source in the blood and 
tissues, and a drop of the last cultivation, whether it be the fiftieth or 
the hundredth, is inserted under the skin of a healthy animal selected 
for the experiment. If it be true, as stated by the experimenters, that 
the original disease is thus reproduced with the microbes of at least three 
or four distinct maladies, this age is distinguished by one of the most 
important discoveries ever made in pathological studies. It remains to 
determine whether this great discovery is of general applicability to the 
infectious diseases with which man is afflicted. If so, it is not improb- 
able that we are on the eve of finding a method by which some at least 
of these maladies may be prevented or mitigated, as smallpox has been 
since the time of Jenner. The result of experiments made by Pasteur 
with the microbes of that fatal malady of the herbivora, known under 
the various names of splenic fever, anthrax, wool-sorter's disease, and 
charbon, encourages this belief. Originating among the herbivorous 
animals, it has in many instances been contracted by individuals who 
have rapidly perished. Many engaged in assorting alpaca and mohair 
have lost their lives by it, some with all the symptoms of profound 
blood-poisoning, without external lesions, and others with redness and 
swelling at some point of infection where a sore or abrasion existed, 
but with speedy blood-contamination. 

The microbe of this malady, the bacillus anthracis, occurs in the form 
of straight filaments with little movement or only with oscillation, and 
producing bright-shining spores. Now comes a very interesting and 
important result of experimentation: Pasteur states that if several days 
elapse between the cultivations the virulence of the parasite diminishes, so 
that he has been able to produce by inoculation with it a mild and never 
fatal form of charbon, which affords immunity in the animal from any 
subsequent attack. This opinion was sustained by a trial experiment 
on sixty sheep. Toussaint and Chaveau claim that they produce a 
similar attenuation of the virus by defibrinating infected blood, heating 
it to 55° C. (131° F.), and filtering it. These experiments awaken the 
hope that the time will come when the acute infectious maladies in man, 
scarlet fever among others, will be rendered less virulent. That one of 
them, to wit, smallpox, has for nearly a century been under our control 
certainly encourages the belief that there is some way to mitigate others 
of the same class which are equally fatal if not so loathsome. 

As yet, observers do not agree in regard to the parasite which is sup- 
posed to sustain a causative relation to scarlet fever. Klebs states that 
it is highly probable that both measles and scarlet fever are produced 
by micrococci, and he has sketched the design and described the 
development of a microbe which he designates the Monas scarlatinosum. 

The London Medical Times and Gazette for Jan. 28, 1882, contains 
an account of the supposed discovery of the scarlatinous microbe by 
Eklund, of Stockholm, an authority in the microscopic examination of 
parasites. He says that scarlet fever is rarely absent from the Swedish 
capital and from the barracks and dwellings on the isle of Skeppsholm. 



200 SCARLET FEVER. 

In the urine of scarlatinous patients he has constantly found a pro' 
digious number of discoid corpuscles, oval or round, their diameter 
being less than 1 \, millimetre, and from ■£$ to y 1 ^- that of a red blood- 
cell. They are colorless or yellowish-white, surrounded by a distinct 
cell-wall, each containing a well-defined nucleus of a deeper hue. Some- 
times one sometimes more of them are seen in the field of the micro- 
scope. They exhibit rotatory or oscillatory movements, especially ob- 
served when a drop of water is added to the fluid. They multiply, as 
Eklund has frequently seen, by fission — first in the microbes, next in 
the nucleus, and lastly in the cell-wall. He cannot say whether they 
develop into a mycelium. At any rate, the development of fine fila- 
ments seems to be exceptional. He has never seen them adhere in 
moniliform chains nor massed as zooglsea. He considers them to be 
veritable schizomycetes, and proposes the name Plox scindens. 

Eklund asserts that he has found these organisms in vast numbers 
in the soil- and ground-water of the isle of SSkeppsholru, in the mud 
of the trenches dug for the water-mains, and in the greenish mould 
upon the walls of the old barracks, where scarlet fever was most rife. 
He states that scarlet fever has occurred in children after drinking milk 
mixed with the ground-water of the island, and he observed a case which 
followed immersion in one of the trenches of the island and the drying 
of the clothes in a small room. In another instance, scarlet fever broke 
out in a block immediately after exposure of the ground-water by exca- 
vations. 

It is evident that the discovery of this microbe under such circum- 
stances does not prove that it is the cause of the disease. This can only 
be determined by inoculation, or by experiments which furnish the con- 
ditions of scientific exactness. Although great progress has been made 
in parasitology during the last decade, it is evident that several years 
of observation and experimentation must elapse before it is clearly and 
definitely ascertained whether, or to what extent, microbes cause scarlet 
fever and the other exanthematic fevers with which it is classified. 

Whether the specific principle of scarlet fever be a microorganism or 
a chemical Substance, its mode of action and effects have been ascertained 
by clinical observations. Without doubt it commonly enters the system 
by the breath, but it may enter in the ingesta, and it infects the blood. 
That it resides in the blood, has been ascertained by inoculation with 
this liquid, by which scarlet fever has been reproduced in its typical 
form. From the blood it enters the tissues and secretions. Hence 
handkerchiefs or linen containing the saliva or mucus of a patient, the 
epidermic scales shed abundantly in the desquamative period, and prob- 
ably also the urinary and fecal evacuations, contain the poison, so as to 
be highly infectious. Even the discharge of a scarlatinous otorrhoea is 
thought by some to be contagious for a considerable time. 

Scarlatina is communicable not only by direct exposure to a patient, 
but also by exposure to objects which happen to be in his room during 
his illness, and to which the poison becomes attached, such as clothing, 
books, and toys; small packages, as we have stated above, sometimes 
convey and disseminate the contagious principle. 

In England observations have been made which show that scarlatina 



ETIOLOGY. 201 

has been communicated by infected milk. The disease occurred in the 
family of a milkman, and the milk, before it was distributed, remained 
for a time in a kitchen which had been occupied by the patients. This 
milk was taken by twelve families, and in six of these the disease 
occurred almost simultaneously at a time when few cases were occurring 
in the locality. There had been no direct exposure to the carrier of the 
milk nor to members of the affected family (Taylor). In another 
instance a woman and her son had scarlet fever while they were serving 
milk to several families, and the disease appeared in all these families 
except one, which consisted of old people (Bell). It is known that 
milk absorbs volatile substances so as to be flavored by them, as is 
shown in the experiment of placing it in an open vessel in a box with a 
pineapple ; and it may in a similar manner become infected by the 
specific principle of scarlet fever, or it may be infected by detached 
particles of epidermis ; which is not improbable when one convalescing 
from scarlet fever is allowed to milk the cows or prepare the milk for 
distribution. 

The scarlatinous virus surpasses that of any other eruptive fever 
except smallpox in its tenacious attachment to objects and its por- 
tability to distant localities. Hence in the literature of the disease are 
the records of many cases in which the poison was conveyed long dis- 
tances, retaining its virulence to the full extent and causing an outbreak 
of the malady in the localities to which it was carried. In New York, 
so frequently has scarlet fever as well as measles and diphtheria been 
contracted from the persons or clothing of well children who come from 
infected houses, that the Health Board now exclude from the public 
schools all children who come from such houses, even though they live 
on separate floors from those occupied by the sick. In one instance 
that came under my notice a washerwomen whose child had scarlet 
fever communicated the disease to an infant in the household where she 
was employed, by placing her shawl over the cradle in which it was 
lying. A physician of my acquaintance went from a scarlet-fever 
patient to a family several streets distant, and took one of their children 
upon his lap. After the usual incubative period this child sickened 
with a fatal form of the malady, and the remaining children of the 
household were in time affected. In New York, scarlet fever has 
seemed to me to be not infrequently communicated through school 
books, which, profusely illustrated by pictures and rendered attractive 
to the young, are often allowed to lie upon the bed of a scarlatinous 
patient and be handled by him during convalescence, or even during 
the course of the fever if it be mild. The young librarian of the cir- 
culating library of a Sunday-school, whose pupils came largely from the 
tenement houses, was occupied a considerable part of a day in covering 
and arranging the books. After about the usual incubative period of 
scarlet fever he sickened with the disease. His two sisters were imme- 
diately removed to a rural township three hundred miles away, and to 
an isolated house where scarlatina had never occurred. About one 
month after his recovery, and after his room had been disinfected by 
burning sulphur and his bedclothes and linen had been thoroughly 
washed, and all articles suspected to hold the poison had been either 



202 SCARLET FEVER. 

disinfected or destroyed, the brother visited his sisters in the country. 
Three weeks subsequently to his arrival one of these sisters sickened 
with scarlet fever, and a w T eek later the other also. It seems that the 
exposure must have occurred several days after his arrival in the country 
from some book or other infected article in his possession. About two 
months elapsed after the last case ; the family had returned to the city, 
the infected room in the country-house had been thoroughly fumigated 
by burning sulphur from morning till evening, when a little girl from 
an inland city remained a few days in this house, and probably often 
entered the room where the young ladies had been sick. In a few days 
she also sickened with a fatal form of scarlatina. Such histories and 
experiences are not infrequent. They are common during epidemics 
of scarlet fever. They indicate an extraordinary attachment of the 
scarlatinous poison to objects, and show that it is not gaseous nor 
readily volatilized. 

A striking example of this fixity of the poison occurred in the prac- 
tice of the late Kearney Rogers, formerly a prominent and much 
esteemed surgeon of New York City. Six children in a family had 
scarlet fever. Three and a half months subsequently another child, 
living at a distance, was allowed to return home and occupy the apart- 
ment in which the sickness had occurred. One week subsequently to 
the date of the return this child sickened with the same malady. 
Elliotson states that a patient with scarlet fever was admitted into one 
of the w r ards of St. Thomas's Hospital, and for two years subsequently 
young persons who were admitted into the ward were apt to take the 
disease. Richardson, of London, relates the following experiences of a 
family whom he attended in the rural district : u At a short distance 
from one of our villaegs there was situated on a slight eminence a small 
clump of laborers' cottages, w T ith the thatch peering down on the beds 
of the sleepers. A man and his wife lived in one of these cottages 
with four lovely children. The poison of scarlet fever entered the poor 
man's door, and at once struck down one of the flock." The remain- 
ing children were now removed some miles away, and after several 
w^eeks one of them w T as allowed to return. With twenty-four hours it 
also took the disease, and quickly died. The walls of the cottage were 
now thoroughly cleaned and whitewashed, the floors scoured, and all 
the wearing apparel either destroyed or washed. Four months elapsed 
after the last sickness when one of the remaining children returned. 
" He reached his father's cottage early in the morning ; he seemed dull 
the next day, and at midnight I was sent for, to find him also the 
subject of scarlet fever. The disease again assumed the malignant 
type, and this child died." Richardson believes that the contagion was 
attached to the thatch, which could not be thoroughly disinfected. The 
fact of this remarkable long-continued attachment of the poison to 
objects, indicating by this fixity that it is a solid, is consonant with the 
theory that it is an organism. 

Incubative Period. — The duration of the incubative period varies 
in t different cases. It is sometimes less than twenty-four hours, as in 
the above case reported by Richardson; in the following well-known 
case, observed by Trousseau, it was one day. A girl arrived in Paris 



INCUBATIVE PERIOD. 203 

from Pau, where there was no scarlet fever, and occupied the same 
apartment with her sister, who was sick with this disease. Twenty-four 
hours after her arrival she also was attacked with the same malady. 

Russeberger attended a child who was exposed at noon to scarlet 
fever, and took the disease on the following night. B. W. Richardson 
(Clinical Essays, 1861, vol. i. p. 94) gives his own experience. He 
had applied his ear to the chest of a patient suffering from scarlet fever, 
and was conscious of a peculiar odor emitted from the patient. He was 
immediately nauseated and chilly, and from that moment he dated the 
beginning of an attack of scarlet fever. In the Transactions of the 
Clinical Society of London, vol. ix., 1878, the late Charles Murchison 
gives the statistics of 75 cases, showing the incubative period, as follows : 

In 4 cases it was not more than 24 hours. 

" 2 " " " " ....". 30 " 

" 3 " " " " 36 " 

" 4 " " " u ..... 40 " 

a i a a u n t 4^ u 

" 4 " u " u 58 " 

k ^ a a a a 54 a 

" 1 " " " " 2J days. 

" 31 cases it was within (time not accurately ascertained) 4 " 
" 2 cases the incubation did not exceed . . . 4£ " 

tt 17 a u "".... 5" " 

a 2 " " " " 6 " 

In three cases Murchison believes that the incubation w T as precisely 
fixed at thirty-six hours, three days, and four and a half days. 

Watson says that a man reached Devonshire on mid-day to see his 
daughter, who had scarlet fever. Two days later he was also attacked. 
Rehn saw a child who was attacked two days after its grandmother 
returned from a case of scarlet fever ; and Zengerle, a girl of ten years, 
residing at Wangen, where there was no scarlet fever, who took the 
disease two days after her mother had returned from visiting a family 
affected with it. Loochner states that a boy aged four and a half years 
was attacked one and a half days after admission into the infected wards 
of a hospital. Armistead, in his annual report on the health of the 
Newmarket rural district, states that three children, coming from a dif- 
ferent part of the district, visited Westley, and stayed next door to a 
child who had scarlet fever six weeks previously, and who was allowed 
to play with these children on the evening of August 13th and morning 
of the 14th. The family then returned home, and on the 18th, four 
days after the exposure, all three children sickened with scarlet fever 
(British Medical Journal, September 30, 1882). 

Ordinarily, therefore, the incubative period, though varying in dif- 
ferent cases, is within six days. Many cases, however, occur in which 
it seems to be longer. Thus, in my practice, scarlet fever appeared in 
a family on April 26, 1882. The patient was immediately removed to 
the third floor and the other children to the basement. All communi- 
cation between the infected room and the basement w r as forbidden, but 
on May 8th, twelve days after the separation, one of these children 
sickened with the disease. Many observers, among whom may be 
mentioned Niemeyer and Copland, believe that the incubative period 



204 SCARLET FEVER. 

may be longer than one week, but, on account of the subtlety of the 
poison and the many modes of transmission, it is possible that in the 
instances of an apparently long incubative period there were other and 
unsuspected exposures. When scarlet fever has been communicated by 
inoculation, as in the experiments of Rostan and others, the incubative 
period has been about seven days, but Gerhardt states that a man was 
attacked four days after an abscess was opened by a knife used upon a 
scarlatinous patient. This variation in the incubative period, which 
also occurs in some other infectious diseases, as diphtheria, is probably 
due mostly to individual differences, some being more susceptible than 
others; but it may be due partly to those obscure meteorological con- 
ditions which we designate the epidemic influence. Probably, as a rule, 
when the disease is quickly developed after exposure, the attack is more 
severe than when several days elapse. 

Contagiousness. — The area of the contagiousness of scarlet fever is 
small. It apparently embraces only a few feet. Therefore, close 
proximity is the necessary condition of its propagation. Hence many 
who are exposed, particularly of those who are remotely exposed, do not 
contract the disease. There is also an idiosyncrasy in some children, so 
that they resist infection even when repeatedly and closely exposed. In 
the New York Medical Record for March 23, 1878, C. E. Billington 
states that of 90 children in 26 families who were exposed to scarlet 
fever, 43 contracted the disease and 47 escaped; whereas, as is well 
known, comparatively few unprotected children escape pertussis, variola, 
varicella, or measles if exposed to either of these diseases. By strict 
isolation, therefore, the spread of scarlet fever is more easily prevented 
than that of most other acute infectious maladies. In the New York 
Foundling Asylum for a number of years children with scarlet fever 
were isolated in a small room attached to one of the wards. The door 
between the two rooms was closed, and not opened during the con- 
tinuance of the sickness. Entrance into the small room was through 
another door, and a nurse was assigned to the scarlet-fever cases, with 
strict directions that she should not mingle with the other children. 
These simple precautions were found sufficient in the various epidemics 
of scarlet fever which occurred in the city to prevent the spread of the 
malady through this institution ; whereas, similar measures were much 
less effectual in arresting the spread of measles and - pertussis. Conse- 
quently, an outbreak of scarlet fever in this institution was usually 
limited to a few cases, while the extension of measles and pertussis was 
arrested with difficulty till a more efficient quarantine was established. 

Variations in Type. — The type of scarlet fever varies greatly in 
different epidemics, and frequently also in cases which occur in the same 
epidemic, even in the same family. One child may have scarlatina so 
mildly that little treatment is required and convalescence soon begins, 
while another has the malignant form, and soon succumbs, notwith- 
standing the prompt employment of the most efficient and appropriate 
measures. Ordinarily, however, if the first case in a family be very 
severe, subsequent cases will present a similar type; but there are 
notable exceptions. This variation in type in different years and dif- 
ferent epidemics is probably not equalled in any other infectious 



SURGICAL AND OBSTETRICAL SCARLATINA. 205 

malady. Consecutive epidemics may present this variation, or the 
same type may continue for a series of years, and then,' from some 
unknown cause, change to one milder or more severe. In England, 
during Sydenham's life, scarlet fever was so mild that he regarded it as 
a trivial affection, requiring little attention, like rotheln of the present 
time, but after the death of Sydenham, Morton and his contemporaries 
in London found, to their sorrow, that the type of scarlet fever was 
very different from that described by Sydenham's pen. The late Dr. 
Graves, of Dublin, and his contemporaries treated a mild type of scarlet 
fever with a very small percentage of deaths — much less than that 
during the preceding generation — and they attributed their success to 
their greater knowledge and more appropriate use of remedies than 
their ancestors possessed and employed. By and by the type changed, 
the mortality of former years was restored, and they discovered that 
their previous success in saving life had been due not to their skill, but 
to the mild form of the malady. A distinguished physician of New 
York treated more than fifty cases of scarlet fever in one of the insti- 
tutions without a single death. A few months afterward the type of 
the malady changed, and his own son perished from it. 

Surgical and Obstetrical Scarlatina. — After surgical opera- 
tions, and sometimes in surgical cases not requiring operative measures, 
a scarlatinous efflorescence occasionally appears upon the whole or 
nearly the whole body, and remains for several days. The following 
were cases of the kind alluded to. They occurred in Guy's Hospital, 
and were published by H. G. Howse in Grays Hospital Reports for 
1879 : On March 15, 1878, Jacobson performed osteotomy upon a 
child suffering from extreme rachitis. The operation was followed by 
a moderate febrile movement (100° to 101°), and after three days by 
the appearance of an efflorescence, with sore throat and the strawberry 
tongue. The osteotomy had been performed under carbolic acid spray 
and with all the details of antiseptic surgery. The rash soon faded, 
the temperature fell, and the child, temporarily separated from the 
other patients from the suspicion that the disease was scarlet fever, was 
brought back to the ward. The subsequent history confirmed the 
diagnosis of scarlet fever, for the skin desquamated, and on April 1st 
abundant albumen was found in the urine. The case terminated favor- 
ably. Three months previously the same operation had been performed 
on the other leg, with no unfavorable symptoms. On April 5th, three 
weeks after the osteotomy, a lipoma was removed from another patient 
aged twenty-one years. The following day the temperature rose to 
101°, and remained at that till April 8th, when it suddenly increased 
to 103°, and a rose-rash occurred over the body, with sore throat. On 
April 9th, Howse excised the elbow-joint of a girl of sixteen years 
having pulpy disease. On the 10th her temperature began to increase, 
and on the 11th reached 105.8°. Toward evening a roseoloid eruption 
appeared over her body, and she was isolated. On April 12th, Dr. H. 
excised a fibroid bursa patellae from a woman of twenty-nine years. 
On the following day her temperature was 99°, but on the 14th it rose 
to 100°, and on the evening of the 15th she had rigors and headache. 
On the morning of the 16th the temperature was 102. 5°, and a roseo- 



206 SCARLET FEVER. 

loid eruption occurred over the face and chest. The surgeons now per- 
ceived that an epidemic of the so-called surgical scarlatina was occurring, 
so as to justify the postponement of other operations. 

In the same volume of Cruijs Hospital Reports, James F. Goodhart 
gives the histories of nearly thirty cases of this disease occurring during 
a series of years in the same hospital. The patients were chiefly chil- 
dren, having the most diverse surgical ailments, among which may be 
mentioned hip disease and abscess, genu valgum without operation, 
necrosis of femur, hydrocele with explorative operation, a scald, a sinus 
over the great trochanter, spinal disease with abscess, tenotomy for club- 
foot, and vesical calculus with operation. The most common disease 
was caries or necrosis with abscess. In cases operated on the intervals 
between the operations and the occurrence of the efflorescence varied 
from two days to more than two weeks. Goodhart, after a careful 
examination of these cases, came to the conclusion that they were for 
the most part examples of true scarlet fever, especially as a considerable 
proportion of them occurred in groups, and there was a known exposure 
of some of the patients to children admitted into the hospital with the 
sequelae of scarlet fever. 

In the British Med. Journ. for Jan. 1879, George May, Jr., reported 
a case of efflorescence in surgical practice which appears to have been 
scarlatinous. A child was operated on for the radical cure of hernia 
on Dec. 4th. Toward the close of the same day he became restless, 
vomited, and his pulse on the following day rose to 136. Forty-eight 
hours after the operation a rash appeared on the chest and arms, the 
abdomen became tense and painful, and on the following day he died. 
The poison, however, in this case may have been septic. 

Hillier remarks {Diseases of Children): "In the hospital for sick 
children, of the children who contract scarlatina a very large proportion 
have been the subjects of a surgical operation within a week before the 
rash appears." Gee says (Reynolds's System of Medicine): "It has 
been doubted by some whether the scarlatiniform rash which sometimes 
follows operations is really scarlatinal. The eruption appears from the 
second to the sixth day after the operation, and in the cases which have 
caused the doubt is very fugitive and the first and only symptom. Yet 
that the disease really is scarlet fever would seem to be proved by the 
following observations : first, that the disease occurs in epidemics ; 
secondly, that in a given epidemic a severe case occasionally relieves 
the monotonous recurrence of the very mild form ; thirdly, that a pre- 
cisely similar scarlatinilla attacks in the same epidemic patients who 
have not been subjected to operation and who have no open sore; and 
lastly, by way of a veritable experimentum crucis, that, however freely 
these patients are exposed to ordinary scarlet fever contagion, after- 
ward, they do not contract that disease." Paget and other distinguished 
London surgeons who have observed this complication of surgical cases, 
believe that the patients have been previously exposed to the scarla- 
tinous poison, and that the surgical diseases or operations furnish favor- 
able conditions for the occurrence of scarlet fever, so that the exposure, 
which probably would have been without result in ordinary health, 
causes an outbreak of the malady. 



SURGICAL AND OBSTETRICAL SCARLATINA. 207 

Those who have reported cases of this form of efflorescence have for 
the most part neglected to state whether the patients had had scarlet 
fever previously, knowledge of which would have aided in the diagnosis; 
but from an examination of the histories of cases, especially those pub- 
lished in the London journals in the last four or five years, there can, I 
think, be little doubt that surgical maladies of a certain kind, especially 
traumatism, do produce a state of system which predisposes to scarlet 
fever, so that this class of patients are especially liable to contract it. 
Therefore, in my opinion, a considerable proportion of reported cases 
of surgical scarlatina are genuine, but in a considerable number, perhaps 
an equal number of such cases, the histories and symptoms indicated a 
septic rather than scarlatinous efflorescence, and in not a few instances, 
when consultations have been held, opinions differed, some diagnosti- 
cating scarlet fever, others septicaemia. In some of the cases I find it 
stated that the fauces presented the normal appearance. Now, faucial 
redness is so generally present in scarlet fever, antedating that of the 
skin and coexisting with it, that its absence is strong evidence that the 
disease is not scarlatinous. Moreover, when, as was true of certain of 
the reported cases, the rash appeared irregularly upon the surface, and 
faded away in two or three days with the abatement of the fever, and 
the conditions for septic absorption were present, the efflorescence was 
probably septicaemia. 

The following were apparently cases of septicaemic efflorescence : A 
child aged five years, (Brit. Med. Journ., Feb. 15, 1879) had inflammation 
of the lymphatic glands in the groin, which suppurated. At the time 
when the abscess was fully formed a rash appeared over the entire body. 
It consisted of numerous red points, but was paler than that of ordinary 
scarlet fever; temperature never above 99°; no sore throat nor desqua- 
mation of cuticle No child exposed .to her took scarlet fever, and her 
sickness could not be traced to infection. In the British Med. Journ., 
Jan. 4, 1879, L. Braxton Hicks states that his son, attending school 
at Reading, was seized with a severe attack of pyrexia, accompanied on 
the second day by delirium -and the occurrence of a rash like scarlet fever 
over the entire surface. He had no decided redness of the fauces, though 
it was perhaps slightly flushed. The right buttock was swollen from 
inflammation, and a large, deep-seated abscess formed near the tuberosity 
of the ischium. When the delirium abated the boy said that he was 
standing the day before the fever began with his legs far apart, when a 
schoolfellow stretched them further by suddenly pulling on one of them. 
The rash, which was nearly universal, lasted three days, and was not 
followed by desquamation. No case of scarlet fever occurred in the 
school before or afterward. In the same volume of the British 3Iedical 
Journal, Surgeon Frolliott, of the East India Service, relates the case of a 
private, aged twenty-three years, and three years in India, who, when on 
duty in the Punjab, was injured by the explosion of an Afghan powder- 
magazine. The accident occurred Dec. 21, 1878. On Dec. 25th a bright 
scarlet rash appeared upon the abdomen and spread over the entire body. 
The following day the eruption was very vivid, like a boiled lobster, and 
it lasted five days. The temperature, which in the beginning had been 
101°, abated to the normal after the rash appeared. No soreness of 



208 SCARLET FEVER. 

throat nor redness of the buccal surface occurred, but the epidermis 
desquamated even from the palms of the hands and soles of the feet. 
Now, the febrile movement of scarlet fever does not cease while the 
efflorescence is distinct. It does not even dimmish when the eruption 
appears, Avhile in the above case it fell to the normal — a common occur- 
rence in septicaemia, even when the blood-poisoning is profound. More- 
over, scarlet fever is so rare in India that Frolliott, after twelve years' 
service, had only heard of one case among Europeans and natives. The 
surgeons who consulted over, the case of this private disagreed in opinion, 
some regarding the disease as septicsemic, others as scarlatinous. But a 
better knowledge of the clinical history of scarlet fever on the part of 
these army surgeons would, I think, have removed all doubt as to the 
diagnosis. 

It is the opinion of some reputable surgeons that the exposure of 
traumatic patients to the scarlatinous poison sometimes aggravates the 
inflammation of wounds, causing them to assume an unhealthy appear- 
ance even though no scarlatina be produced. The late Dr. Solly made 
the remark, "Whenever a case of surgery in private practice takes on a 
highly phlegmonous appearance I am always sure to find break out, in 
the inmates of the house, either erysipelas or scarlet fever" {British Med. 
Journ., Feb. 15, 1879). We will see that the scarlatinous poison some- 
times causes pharyngitis or nephritis without producing the general dis-. 
ease. In a similar manner it seems that it may aggravate open wounds, 
intensifying the inflammation in them, while there is no efflorescence or 
other symptom to show that scarlatina itself is present. The poison 
appears to act entirely locally in such cases. 

Paget, in his Clinical Lectures, says: "I think it not improbable 
that in some cases results occurring with obscure symptoms within 
two or three days after operations have been due to the scarlet-fever 
poison, hindered in some way from its usual progress." Play fair, 
in his remarks on the puerperal state, adds: "Mr. Spencer Wells in- 
forms me that he has seen cases of surgical pyaemia which he had reason 
to believe originated in the scarlatinal poison ; and his well-known suc- 
cess as an ovariotomist is no doubt, in a great measure, to be attributed to 
his extreme care in seeing that no one likely to come in contact with his 
patients has been exposed to any such source of infection." Opinions 
like these, held by such prominent members of the profession and sus- 
tained by many observations, should certainly induce physicians to pre- 
vent, so far as possible, exposure of their surgical patients, especially if 
they have sores or wounds, whether by traumatism or scalpel, to the 
scarlatinal poison. 

Obstetrical Scarlatina. — Women during convalescence after child- 
birth are very liable to contract scarlet fever. In the New York Infant 
Asylum, which has maternity wards, a woman was admitted from a 
house in which scarlet fever was prevailing, and assigned to a cot next 
that occupied by one of the waiting women, who was confined soon after- 
ward. Her labor was favorable, but three days afterward she took 
scarlet fever, and another lying-in patient contracted it from her. The 
sore throat and desquamation were characteristic. It has come to my 
knowledge that a physician of New York, in whose family scarlet fever 



OBSTETKICAL SCARLATINA. 209 

was occurring, attended three women in succession in their confinement, 
and all contracted scarlet fever, which presented the characteristic symp- 
toms, and two of them died. Experienced and cautious physicians of 
New York, aware of the danger, do not go directly from a scarlatinous 
patient to an obstetrical case, but avoid the risk by intermediate visits to 
other patients or by remaining for a time in the open air. 

Playfair, remarking on this subject, says: " There is good reason to 
believe that the contagium of zymotic diseases may produce a form of 
disease indistinguishable from ordinary puerperal septicaemia, and pre- 
senting none of the characteristic features of the specific complaint from 
Avhich the contagium was derived. This is admitted to be a fact by the 
majority of our most eminent British obstetricians, although it does not 
seem to be allowed by Continental authorities, and it is strongly contro- 
verted by some writers in this country. It is certainly difficult to recon- 
cile this with the theory of septicaemia, and we are not in a position to 
give a satisfactory explanation of it. I believe, however, that the evi- 
dence in favor of the possibility of puerperal septicaemia originating in 
this way is too strong to be assailable. The scarlatinal poison is that 
regarding which the greatest number of observations has been made. 
Numerous cases of this kind are to be found scattered through our 
obstetric literature, but the largest number are to be met with in 
a paper by Braxton Hicks. Out of 68 cases of puerperal disease 
seen in consultation, no less than 37 were distinctly traceable to the 
scarlatinal poison. Of these, 20 had the characteristic rash of the 
disease, but the remaining 17, although the history clearly proved 
exposure to the contagium of scarlet fever, showed none of its usual 
symptoms, and were not to be distinguished from ordinary typical cases 
of the so-called puerperal fever. On the theory that it is impossible 
for the specific contagious diseases to be modified by the puerperal state, 
we have to admit that one physician met with 17 cases of puerperal 
septicaemia in which, by a mere coincidence, the contagion of scarlet 
fever had been traced, and that the disease nevertheless originated from 
some other source — a hypothesis so improbable that its mere mention 
carries its own refutation." 

Parturition, like traumatism, furnishes in an eminent degree the con- 
ditions in which septic poisoning occurs, and the efflorescence which 
often accompanies septicaemia bears, as we have seen, a very close re- 
semblance to that of scarlet fever. Hence in many instances the same 
difficulty is present in making a differential diagnosis between septic 
and scarlatinous blood-poisoning in obstetrical cases which occurs in 
surgical practice. But, according to my observations, an efflorescence 
occurring during the week following parturition is in most instances 
septic. It is only in exceptional cases that it is scarlatinous, and there 
is little danger that the accoucheur, engaged in general practice and 
visiting scarlatinous patients, will communicate scarlet fever through 
his person or clothing if he exercise proper precautions. His short 
stay in the sick-room and his outdoor exercise in visiting cases prevent 
infection of his person or dress. But if, as Playfair believes, the scar- 
latinal poison sometimes produces in parturient women a puerperal 
fever in which the characteristic scarlatinal symptoms are lacking, and 

14 



210 



SCARLET FEVER. 



which, in the present state of our knowledge, is not distinguishable 
from ordinary septic fever, certainly the scarlatinous virus sustains a 
much more frequent causative relation to childbed fever than has been 
heretofore supposed. 

Infants under the age of six months do not ordinarily contract 
scarlet fever, although fully exposed, and those under four months 
nearly possess immunity. Still, this disease has been observed in new- 
born infants, contracted apparently, through the placental circulation. 
Tourtual states that a woman waited upon her own husband and child, 
both of whom had scarlet fever, during the eighth and ninth months of 
her pregnancy, till near her confinement. Though she had no symp- 
toms of scarlet fever, her infant had unusual redness of the skin and 
buccal surface and difficulty of swallowing up to the fifth day. On the 
ninth day desquamation began, and at a later stage the nails of the 
fingers and toes separated. A case having a history in some respects 
similar is related by Megnert, but the symptoms were anomalous for 
scarlet fever, and the disease may have been ordinary septic fever. On 
the other hand, in one instance in my practice a mother had scarlet 
fever, beginning about the third day after her confinement, and although 
she suckled her infant and it was constantly in bed with her, it had no 
symptoms of scarlet fever, although it became affected immediately after- 
ward by a severe form of eczema, probably from the altered quality of 
the milk ; and in two instances observed by Murchison new-born infants 
remained healthy, although their mothers suffered from scarlet fever. 

After the age of six months the liability to scarlet fever increases till 
the close of infancy, children between the ages of six months and one 
year being less liable to contract the malady than during the second 
year, and those in the second year being less liable to it than those in 
the third year. Murchison collected the statistics of deaths from scarlet 
fever in England and Wales during a series of years ending with 1861. 
The number of deaths aggregated 148,829, and the percentage of deaths 
at different ages was as follows : 

per cent. 



Deaths under 1 year 










6.7 


" between 1 and 2 years 










. 14.09 


" " 2 and 3 " 










16.00 


" " 3 and 4 " 










15.13 


" " 4 and 5 " 










11.9 


" " 5 and 10 " 










25.9 


" " 10 and 15 " 










5.8 


" " 15 and 25 " 










2.6 


" " 25 and 35 " 










0.8 


" over age of 35 " 










0.8 



Among the deaths were ten cases above the age of eighty-five years, so 
that scarlet fever, though especially a disease of childhood, may occur 
in any decade of life ; but old age, like early infancy, almost possesses 
immunity from it. 

I have preserved the records of the ages of, 145 consecutive cases 
occurring in private practice. If we add to these 58 cases observed by 
Prof. Octerlony {Amer. Jour, of Med. Sci., July, 1882) we have the 
statistics of the ages of 203 cases, which are embraced in the following 
table : 



CLINICAL FACTS REGAKDING SCARLET FEVER. 211 

Under 1 year 3 

From 1 to 2 vears 25 

2 to 3 " " 43 

3 to 5 " 57 

5 to 10 " .53 

10 to 15 " 13 

15 to 20 " S 

20 to 30 " 4 

30 to 40 « 2 

Total. . . .203 

Clinical Facts regarding Scarlet Fever.— As a rule, scarlet 
fever occurs but once, one attack conferring immunity from the disease 
for life; but there are exceptions. In 1869, I attended a child with 
fatal scarlet fever who three years previously, it was stated, had passed 
through a first attack with all the characteristic symptoms. The fol- 
lowing case occurred in a family attended by the late Dr. Herzog : 

R , a boy of six years, had scarlet fever in a mild form in January 

and February, 1875, followed by moderate desquamation. In July of 
the same year he was kicked by a horse in the street, receiving a deep 
scalp-wound which required three stitches. Three days afterward he 
had, to appearance, a second attack of scarlet fever, attended by high 
febrile movement, and followed also by desquamation. It was believed 
by Dr. H. to be a genuine case, and was so treated. I am not able to 
state as regards the presence of soreness of the throat, and doubt arises 
whether this second attack may not have been septicaemia In April, 
1876, a third attack occurred, which I saw from the beginning. It was 
accompanied by all the characteristic symptoms — injection of the fauces, 
an efflorescence continuing the usual time, followed by desquamation 
and albuminuria, the latter remaining several weeks. Richardson 
states that three distinct attacks occurred in his own person, and a 
student attending the lecture at which this was mentioned informed the 
doctor that he also had had scarlet fever three times. 

Sometimes a second attack occurs so soon after the first that it has 
been described as a relapse. The following was a case in point in the 
practice of Godneff (Meditz. Vestnik., No. iv., iV. Y. Med. Bee, 
April 30, 1881): A youth of seventeen years contracted scarlet fever 
while taking care of a child. It began with a chill, and he had the 
usual efflorescence, sore throat, and tumefaction of the cervical glands. 
An exudation appeared upon his tonsils and uvula, and his temperature 
reached 104°. The urine contained a trace of albumen, the rash in due 
time faded, and the epidermis exfoliated. On the fifteenth day, when 
he was about ready to leave the hospital, he again had a chill, followed 
by fever. The temperature reached 105.2°, the rash reappeared over 
the entire surface except the face, diphtheritic exudations occurred upon 
the fauces, and the urine, the quantity of which was diminished, again 
became albuminous. This second efflorescence faded on the twenty- 
fourth day, and on the twenty-seventh exfoliation began. Hillier says : 
" I have seen a young woman in the fever hospital suffering from a second 
attack of scarlatina, the first attack having occurred five weeks pre- 
viously. She had quite recovered from her first illness, and was acting 
as nurse. In both seizures the rash, the sore throat, and other symp- 



212 SCARLET FEVEB. 

toms were characteristic. The relapse or recurrence was less severe 
than the primary disease." Cases of a fourth, or even of a greater 
number of attacks, have been reported. The first seizure is sometimes 
milder, but in other instances is more severe, than those which follow. 

Exposure to the scarlatinous poison not infrequently produces pharyn- 
gitis without the occurrence of scarlatina, and the inflammation is usually 
severe, accompanied by pain in swallowing and marked febrile move- 
ment. This phlegmasia is distinguished from scarlet fever by its shorter 
duration and the absence of the efflorescence. It occurs in adults as 
well as in children, and in those who have had, as well as in those who 
have not had scarlatina. So far as I have observed, it is very seldom 
accompanied or followed by any of the complications or sequelae so com- 
mon in and after scarlet fever. It cannot be distinguished from ordinary 
pharyngitis except in the manner in which it occurs, and one attack 
does not preclude another. The late George B. Wood made the remark 
that he never attended a case of scarlet fever without sufferino- from 
sore throat. The following were examples of this form of pharyngitis : 
On Jan. 17, 1882, I was called to a boy of three years with severe 
scarlet fever, ushered in by convulsions. On the following day his sis- 
ter, aged seven and three-fourths years, whom I had attended a year 
previously during a severe attack of scarlatina, and who had been almost 
constantly with the brother, became very ill, with a temperature of 
103.5°. Examination revealed severe inflammation of the fauces, with- 
out pseudo-membrane or any other exudation except muco-pus. On 
Jan. 19th an older brother, nine years, whom I had attended in scarlet 
fever three years previously, was affected in the same way, his temper- 
ature being 104° and his respiration guttural and noisy, especially 
during sleep, in consequence of the great amount of faucial swelling. 
At times he was delirious. The inflammation in both cases began to 
abate about the third day, and had disappeared by the close of the week. 
That the contagium of scarlet fever may be received into the system and 
cause pharyngitis, while the patient has immunity from scarlet fever 
through a previous attack, and that this inflammation may occur any 
number of times, as in the case of Dr. Wood, are remarkable facts. 

Now and then crises occur which appear to show that the scarlatinous 
poison may affect the kidneys, producing nephritis, while there is no 
other manifestation of its influence. Thus in my practice a lady of 
about forty-five years constantly attended her son, sleeping by his side, 
during an attack of scarlet fever. Her health had previously been good. 
When the boy was convalescent, as her appetite failed and she was in- 
disposed, a careful examination revealed the fact that she had albumin- 
uria, although she had had no sore throat or other symptoms of scarlet 
fever. After several weeks of treatment her disease was removed, and 
she has remained well since. In the British Med. Jour, for Nov. 29, 
1879, it is stated that in a family four girls were found to be suffering 
from desquamative nephritis. One of them had recently had scarlet 
fever, but the other three had presented no symptoms whatever of this 
disease. Such cases, although probably rare, appear to show that, as 
the scarlatinous poison may produce inflammation of the fauces without 
the occurrence of scarlet fever, so it may cause nephritis without pro- 



SYMPTOMS. 213 

ducing the general disease, or apparently disturbing the functions, or 
changing the state of other parts, except the kidneys. 

Symptoms. — Ordinary Form. Scarlet fever usually begins abruptly, 
so that the exact time of its commencement can be fixed. If any pre- 
monitory symptoms occur, they are slight, so as scarcely to attract atten- 
tion, as languor or the appearance of fatigue. A dusky aspect of the 
surface may occasionally be observed during the few hours preceding 
the attack. In some children the first symptom is chilliness, and oc- 
casionally a distinct chill occurs. In the adult a chill is ordinarily the 
first symptom. With or without the initial chilliness, febrile movement 
occurs, of variable intensity according to the severity of the type, and 
accompanied by such symptoms as usually arise in a febrile state of 
system, as cephalalgia, anorexia, and thirst. The pulse rises to 110, 
120, or more per minute, the temperature to 102°, 103°, or 104° ; the 
skin is hot, face flushed, and the eyes bright. Even in cases that are 
not malignant or grave, and that give indications of a favorable result, 
there is often more or less stupor, with transient delirium and sudden 
starting or twitching of the extremities, showing that the cerebro-spinal 
axis is involved. 

Vomiting is a common symptom in the beginning of scarlet fever, 
occurring before the appearance of the efilorescence. It therefore has 
diagnostic value when the nature of the case is still doubtful. In some 
patients it is an initial symptom, but in others some hours have elapsed 
when it occurs. I recorded its presence or absence in 214 patients, with 
the following result: present in 162 patients, absent in 52. In severe 
forms of the disease it is rarely absent, and if it do not occur it is probable 
that the case will be mild, requiring little treatment, and having a favor- 
able termination. In epidemics of unusual mildness the number of cases 
without vomiting may be in excess of those in which this symptom 
occurs. It appears to be due to functional disturbance of the cerebro- 
spinal system, and may therefore be properly regarded as a nervous 
symptom. In severe cases the vomiting is apt to be repeated, not only 
on the first but on subsequent days, and we shall see that in cases of great 
gravity, in which a fatal termination is not improbable, persistent vomit- 
ing, by which the food and stimulants so urgently required are rejected, 
interferes seriously with successful treatment. In a few cases embraced 
in my statistics nausea without vomiting was recorded. The bowels in 
ordinary scarlatina act regularly or are slightly constipated. Diarrhoea, 
which so commonly accompanies the persistent vomiting in malignant 
cases, if it occur in this form of the malady is slight and transient and 
due to accidental causes. The food, if it be given in the liquid form and 
cool, is usually taken readily, on account of the thirst, except when 
deglutition is rendered painful by the pharyngitis. 

The symptoms pertaining to the nervous system vary according to the 
severity of the disease and the temperament of the patient. Many 
children during the progress of the common form of scarlet fever 
present a dull or apathetic appearance. They lie much of the time 
with their eyes closed; others are more restless, and not a few, if the 
fever be considerable, have occasional twitchings of the limbs and more 
or less headache. Eclampsia sometimes occurs on the first day, especially 



214 SCARLET FEVER. 

in those predisposed to it, even when the subsequent course of the dis- 
ease is mild and favorable. This complication, very grave and usually 
fatal when it occurs at a later stage, is in most instances, when it takes 
place on the first day, readily controlled by proper remedies and with 
little detriment to the patient. But if it be attended by high elevation 
of temperature and marked drowsiness, approaching the comatose state, 
it is very serious upon the first as well as upon subsequent days. Nervous 
symptoms occurring in the beginning of scarlet fever, when it has the 
ordinary favorable type, begin to abate in three or four days, but if they 
supervene at a later date, and especially in the declining stage, they possess 
more gravity, since they then not infrequently result from and indicate 
renal complication. 

Early in the disease, nearly as soon as the commencement of the fever, 
the faucial and buccal surfaces become inflamed, as shown by redness, 
swelling, and tenderness. The physician summoned in the beginning 
of an attack will already, at his first visit, observe hyperaemia of the 
fauces, with points of deeper injection than over the general faucial 
surface, and soon the buccal surface also participates. The inflamma- 
tion at first produces preternatural dryness, and this is followed by a 
viscid secretion. The papillae of the tongue enlarge and become promi- 
nent, giving rise to the appearance known as strawberry tongue which 
is so common in scarlet fever. This state of the buccal and faucial 
membrane continues throughout the disease. A thin fur appears upon 
the tongue on the first day, and it increases on the second and third 
days, after which it is usually detached, exposing the surface of the 
organ, which has a deep red hue, but in not a few patients the fur 
remains or is reproduced as soon as shed. Except in the mildest cases 
the Schneiderian membrane also participates in the inflammation as the 
disease advances, so that a thin, irritating discharge containing leu- 
cocytes or pus-cells, flows from the nostrils. The skin is hot and dry, 
and cutaneous transpiration nearly checked. The respiratory system 
is rarely involved in any notable manner unless there be a compli- 
cation. Many have no cough whatever, while others have a slight 
cough, due to the fact that the inflammation, of a catarrhal form, has 
extended from the fauces to the surface of the glottis. Slight accelera- 
tion of respiration, corresponding with the degree of fever, may also be 
observed. The kidneys commonly act regularly and normally during 
the first days, any serious impairment of their functions being rare 
before the close of the first week. 

When the symptoms described above have continued from six to 
eighteen hours the efflorescence appears. It is first observed about the 
ears, neck, and shoulders, in reddish patches fading into the normal 
hue. These patches extend and unite, and in the course of a few hours 
the trunk and upper extremities, and finally the legs, are covered. The 
scarlatinous rash usually, when fully developed, resembles that produced 
by external heat or the application of a sinapism. It has been likened 
to the appearance of a boiled lobster, but there are numerous minute 
points of a deeper or duskier hue than the surface generally. In many 
patients the rash appears, especially over the abdomen and lower ex- 
tremities, as minute, thickly set points, with the skin of normal appear- 



SYMPTOMS. 215 

ance' between them. Henoch, of Berlin, says of scarlet fever : " In 
general, the moderate grades of eruption prevail, the skin, when seen 
from a distance, presenting a diffuse, more or less scarlet redness, while 
on closer inspection it is found that this redness is composed of innu- 
merable red points closely situated together, and separated from one 
another by very small paler portions of skin. The dark-red points 
appear to correspond to the hair follicles." On passing the finger over 
the efflorescence no distinct prominences are observed, but a sensation 
of roughness is sometimes imparted from engorgement of the cutaneous 
papillae. The rash disappears on pressure, but it immediately reappears 
when the pressure is removed. Its slow return is evidence of sluggish 
circulation, and it indicates a grave and dangerous form of the malady. 
The color is then usually a dusky instead of a bright red. The efflo- 
rescence is most marked in dependent parts, as along the back, over the 
chest and abdomen, and in the flexures of the joints. Parts pressed 
upon by the bedclothes, which confine and intensify the heat, present a 
deeper coloration than other portions of the surface. Often, especially 
in mild cases, the rash is absent from portions of the surface where it 
commonly appears, while it presents its typical character elsewhere. 
Tardy and incomplete establishment of the rash when the symptoms 
indicate an attack of ordinary or more than ordinary severity is com- 
monly due to some perturbating cause, especially diarrhoea. In the 
London Lancet for Aug. 16, 1879, cases are related of supposed 
scarlet fever without the rash, cases in which pharyngitis and stomatitis 
with the strawberry tongue occurred, without efflorescence upon the 
skin ; but it is to be remembered, as stated above, that the inflamma- 
tions which commonly attend or follow scarlet fever, particularly the 
pharyngitis and nephritis, not infrequently occur in those who have 
already had scarlatina, and occur more than once from fresh exposure 
to scarlatina patients. These inflammations, occurring under such cir- 
cumstances, appear to be purely local maladies, produced by the scarla- 
tinous virus ; and it seems to me a question whether, in the so-called 
scarlatina without efflorescence, the inflammations which are present, 
and which undoubtedly have a scarlatinous origin, are not local in their 
nature, instead of being local manifestations of the constitutional disease. 
The burning and itching sensation produced by the rash increases the 
restlessness of the patient, and is sometimes the most annoying of the 
symptoms. 

The temperature in the common favorable forms of scarlet fever 
usually varies from 101° in the mildest cases to 103° or 104° in those 
more severe. If it attain 105° or over, the case is properly designated 
grave or severe. The febrile movement ordinarily fluctuates but little 
from day to day till the fourth or fifth day, when, if the case be favor- 
able and no complication occur, it begins to decline. The temperature 
is as high in the beginning of the attack as subsequently. 

The symptoms pertaining to the digestive system during the initial 
period of scarlet fever have been sufficiently described. The subsequent 
symptoms referable to this system do not differ materially from those 
present in the beginning, except the absence of vomiting. The lips 
are dry and often cracked. The inflammation of the mouth and throat 



216 SCARLET FEVER. 

continues, with anorexia and thirst. With the decline of the disease 
the appetite gradually returns, but it is not till the close of the second 
week that it is fully restored. Great and continued disturbance of the 
digestive apparatus, seriously interfering with the nutrition, pertains to 
the malignant forms of scarlet fever. 

The urine is high-colored, and in robust children during the first 
days of scarlet fever it frequently deposits urates on cooling. Gee, who 
has carefully investigated the state of the urine in scarlet fever, says 
that the quantity of water is diminished and the urea is not necessarily 
increased during the pyrexia; that the chloride of sodium is diminished 
till the fourth, fifth, or sixth day, and that the phosphoric acid is dimin- 
ished during the climax of the pyrexia, though not in the first three 
or four days. In one case he made a daily estimation of the amount of 
uric acid, and found it greatly diminished on the second and third days, 
normal on the fourth, and much increased on the fifth. He believes 
that similar variations are common in the quantity of the products 
excreted in the urine. Bile may also appear in the urine, coincident 
with a yellow tinge of the conjunctiva. 1 

The duration of scarlet fever varies in different cases. If the attack 
be very mild, with little efflorescence, the febrile movement may decline 
by the fourth or fifth day ; but if the disease be severe, little or no 
amelioration of symptoms may occur before the twelfth or fourteenth 
day, even when no complication has occurred to increase the tempera- 
ture or cause aggravation of symptoms. Octerlony, who estimated the 
duration of scarlet fever from the commencement of febrile symptoms 
to " the disappearance of fever, with marked improvement in leading 
symptoms," .... "found that the average duration of the disease in 
forty cases was six and one-sixth days. The minimum duration in a 
very slightly marked case was three days : the maximum duration was 
fourteen days." In general, prolongation of fever beyond the usual 
time is due to some complication — more frequently to unusually severe 
pharyngitis, with accompanying cellulitis, than to any other cause. 

The malady whose commencement was so abrupt declines gradually. 
In ordinary cases, by the close of the first week or in the beginning of 
the second the rash becomes less and less distinct, and finally dis- 
appears, as do also the redness and swelling of the buccal and faucial 
surfaces. The engorgement of the tonsils and of the papillae of the 
tongue subsides, the appetite returns, the countenance brightens and 
becomes natural, and the child, who during the height of the fever 
scarcely noticed objects or noticed them with indifference or even re- 
pugnance, can be amused as before his sickness. 

Desquamation succeeds. This begins at about the sixth day, and is 
not completed till the tenth or twelfth day ; often not till the close of 
the third or in the fourth week. The amount of desquamation corre- 
sponds with the intensity and duration of the efflorescence, or rather of 
the dermatitis which produces the efflorescence. If the efflorescence 
have been slight and partial, it will be slight, perhaps scarcely appre- 
ciable, but if the rash have been general, full, and protracted, exfolia- 

1 Article on scarlatina in Keynolds's System of Medicine. 



SYMPTOMS. 217 

tion occurs upon every part. It begins about the face and neck, and 
within a day or two appears upon other parts. Where the skin is thin 
the epidermis as it is detached presents a furfuraceous appearance ; 
where it is thick, as upon the palms of the hands or soles of the feet, it 
separates in layers of considerable thickness. 

Such is a brief description of scarlet fever when it pursues its normal 
course without any disturbing element, but there is no other disease in 
which complications and sequels so frequently occur. The liability to 
them renders the prognosis in every case doubtful. They largely 
increase the percentage of deaths. They occur both in mild and severe 
forms of scarlatina. 

The difference in type in different cases and epidemics has already 
been alluded to. Scarlet fever is sometimes so mild, and its symptoms 
so slight, that the diagnosis is necessarily uncertain. In the spring of 
1866 I was called to an infant thirteen months old who had slight 
pharyngitis and an indistinct rash over a part of the surface. In two 
days the eruption had disappeared, and the health within a day or 
two was apparently fully restored. Diagnosis would have been 
doubtful except for sequelae which clearly indicated the scarlatinous 
nature of the attack. In another instance two children passed through 
the entire course of scarlet fever playing every day in the street. 
Although the intelligent grandmother saw the rash upon them, its 
nature was not suspected, as it was midsummer and cases of prickly 
heat common, till nearly two weeks afterward, wdien one of the chil- 
dren had nephritis and anasarca ending fatally. In cases so mild as 
these the heat of surface is but slightly increased, the pulse but little 
accelerated, and the rash usually does not occupy so much of the 
surface as in ordinary cases; the appetite is not lost, though dimin- 
ished, and the thirst is moderate. 

Between scarlet fever so mild that it terminates in four or five days, 
and that of the grave or malignant type presently to be described, all 
grades of severity exist. Scarlet fever occurs in all forms from mild to 
severe, but certain symptoms characterize grave or malignant cases — 
symptoms which are absent or much less prominent in ordinary scarlet 
fever. Therefore the grouping of cases according to the type is proper, 
and it facilitates the studying of the disease. 

Grave Form (malignant scarlet fever). — This form of the disease is 
in some epidemics common, while in others it is rare. The symptoms 
which characterize it are severe from the beginning, those of the nervous 
system predominating at first, such as intense cephalalgia, restlessness 
or stupor, sudden twitching of the muscles, and perhaps delirium, or 
even convulsions. Many pass rapidly into coma and die within two or 
three days, succumbing to the intensity of the scarlatinous poison while 
the malady is still in its commencement. The rash is dusky. It dis- 
appears by pressure, and returns slowly when the pressure is removed, 
showing extreme sluggishness of the capillary circulation. Some 
patients are very drowsy, lying in a semi-comatose state except when 
aroused, and if aroused are very restless. Others are constantly rest- 
less. If placed in one position on the bed, they throw themselves in 
another in a half-conscious or unconscious state. They do not speak, 



218 SCARLET FEVER. 

or they mutter like those affected by the graver forms of typhus, calling 
the names of playmates or talking incoherently about things which in- 
terested them when well. The thermometer placed in the axilla is 
found to rise above 103°, which is a safe average, to 105° or even 
107°, and the heat of the surface is pungent except when the case 
approaches a fatal termination, when the extremities, ears, and nose 
may be cool while the trunk and head are extremely hot. The pulse 
from the first is rapid, ranging from 130 as the minimum in a malig- 
nant case to a frequency which can scarcely be counted. A very 
frequent pulse is nearly always feeble and compressible. Irritability 
of the stomach is one of the most common symptoms in grave cases, so 
that many patients immediately reject the nutriment and stimulants 
which are so urgently required to sustain the vital powers. The vomit- 
ing, therefore, if frequent and severe, greatly increases the danger, and 
in not a few instances this symptom is associated with diarrhoea, which 
also tends to increase the prostration. 

Severe and dangerous nervous symptoms, due to the intensity or 
activity of the scarlatinous poison, occur chiefly within the first three or 
four days. Grinding the teeth, sudden muscular twitching, delirium, 
convulsions, and profound stupor occur for the most part within this 
time. Afterward the danger is mainly from exhaustion, unless in the 
second week or subsequently, when nervous symptoms may arise from 
uraemia. 

Those who survive the onset of malignant scarlet fever often have in 
the course of a few days severe pharyngitis with extension of the in- 
flammation to the lymphatic glands and connective tissue around the 
angle of the jaw. These inflammations cause more or less external 
swelling. The faucial turgescence around the entrance of the larynx, 
with the accompanying secretions of viscid mucus or muco-pus, often 
causes noisy respiration, and many at this stage of the attack breathe 
with the mouth constantly open to facilitate the ingress of air. 

Ordinarily, no discharge occurs at first from the nasal surface, but as 
the disease continues, if the type remain severe, defluxion of thin muco- 
pus takes place from the Schneiderian surface, which frequently excori- 
ates the cheek. The lips also are frequently sore and swollen. 

In malignant cases the disease is more protracted than when the type 
is mild. Thus in a recent case in my practice the rash was still distinct 
at the close of the second week, though the temperature had fallen from 
105° to 102° and some desquamation had appeared. Long continuance 
of the febrile movement is, however, oftener attributable to some inflam- 
matory complication than to the primary disease. 

In all epidemics of a severe type cases now and then occur in which 
the poison is so intense, or it acts with such frightful energy, that death 
occurs even within the first day. The patient is overpowered at the 
outset of the disease by the virulence of the specific principle, perishing 
in coma, preceded perhaps by convulsions. The autopsy in such cases 
reveals hyperemia of the brain and cranial sinuses, blood of a dark red 
color, capillary hemorrhages in various parts, a flabby heart, and perhaps 
some engorgement of the spleen and kidneys. 

Usually, malignant scarlet fever exhibits its severe type from the 



IRREGULAR FORMS. 219 

first, but cases sometimes occur which seem mild and favorable for a 
few days, when severe symptoms suddenly supervene. This change 
from a mild to a dangerous disease is, however, most frequently, I 
think, due to some complication. 

Irregular Forms. — Deviation from the normal type in scarlet fever 
is usually due to some perturbating cause, which is often a preexisting 
or coexisting disease, or a disordered state of system through causes dis- 
tinct from scarlatina. Thus, a little girl in my practice had the symp- 
toms of scarlet fever, such as febrile movement and inflammation of 
the buccal and faucial surfaces, nearly a week before the scarlatinous 
eruption appeared. During this time the patient had an intestinal 
catarrh, with diarrhoea, which declined when the rash occurred. This 
intestinal disease was the apparent cause of the irregularity in the 
malady. If scarlatina occur during a severe attack of entero-colitis 
attended by purging, the defluxion from the intestinal surface may be 
such that no efflorescence appears. Severe scarlet fever itself some- 
times appears to cause gastro-intestinal catarrh so as to produce an 
afflux of blood toward the intestinal tract and away from the skin. 
Practitioners occasionally meet cases like the following, which I recall 
to mind : In a family where scarlatina was prevailing a little child 
early after the commencement of symptoms which seemed to be plainly 
referable to this exanthem was seized with vomiting and purging, which 
continued till death occurred on the third day. No efflorescence appeared 
on the skin, but the symptoms indicated the presence of severe intestinal 
catarrh, complicating and masking scarlatina. We are aided in the diag- 
nosis of such cases by observing the faucial redness, and we may discover 
a faint efflorescence upon parts of the surface, as about the groin or in 
the flexures of the joints. In another instance an infant in the warm 
months, having protracted entero-colitis, the usual summer epidemic 
of the cities, had the characteristic symptoms of scarlet fever, which 
was present in the family, but the diarrhoea continued and no rash 
appeared. 

In one who is much reduced by an antecedent disease, especially if, 
like the intestinal catarrh mentioned above, it produces a decided afflux 
of blood away from the surface and toward the interior of the body, the 
eruption is commonly tardy in its appearance, indistinct, or wholly 
absent. Thus, severe inflammations of internal organs not infre- 
quently render scarlet fever irregular. On the other hand, some mal- 
adies occurring in connection with this exanthem do not change its 
symptoms, but themselves undergo modification. Pertussis may be cited 
as an example, the cough of which is sometimes modified by an inter- 
current attack of scarlet fever, the symptoms of the latter disease under- 
going little change. 

Scarlet fever may also be irregular without any apparent perturbatino- 
cause. In 1867 I attended a young lady whose previous health had 
been good, and whose brother was sick at the time with scarlet fever. 
She had considerable febrile movement, with severe pharyngitis, and, 
though her surface was repeatedly examined, no efflorescence was seen. 
Two weeks subsequently she was affected with severe nephritis, anasarca, 
effusion into at least one of the pleural cavities, oedema of the luno-s, and 



220 SCARLET FEVER. 

according to my diagnosis, hydro-pericardium, the case ending fatally. 
Rilliet and Barthez state that a second attack of scarlet fever is more 
likely to be irregular than the first. Probably this opinion is correct, 
especially if only a short time have elapsed between the two seizures. 
Still, as we have already stated, both seizures may be typical, and the 
second more severe than the first. 

It would be impossible to make a clear and positive diagnosis of cer- 
tain cases of irregular scarlet fever, in which cerebral, pulmonary, or 
gastro-intestinal symptoms predominate, were it not for the fact that 
they occur in connection with other cases of scarlet fever or are followed 
by sequelae which evidently have a scarlatinous origin. 

Occasionally, the eruption, if it be intense or if a certain condition of 
system be present in the patient, is accompanied by more or less extrava- 
sation of blood-corpuscles from the capillaries, usually in points, so that 
the redness does not entirely disappear on pressure. In rare instances 
certain of the exanthematic fevers present an extreme hemorrhagic char- 
acter, so as to be beyond the reach of remedies, and of necessity speedily 
fatal. Hemorrhagic cases of this severe form are probably more com- 
mon in variola than in the other fevers, but I have met a notable case 
in what was diagnosticated scarlatina. In June, 1881, a man in his 
thirty-second year, whose previous health had not been good, though he 
had no defined ailment and had been able to follow his occupation of 
harness-maker, suddenly became very ill, with high febrile movement 
and faucial inflammation, attended by marked prostration. After some 
hours an intense eruption of a scarlatinous appearance covered nearly 
the entire surface, and on the following day hemorrhages began to occur. 
The urine contained a large proportion of blood; each conjunctiva was 
raised by hemorrhages underneath (ecchymosis), so that its natural 
color w T as lost, the eyelids were closed with difficulty, and blood flowed 
from the nostrils, gums, and under the skin, forming hemorrhagic 
points and blotches. One of the consulting physicians, perceiving the 
resemblance to hemorrhagic variola as described by Hebra, suspected 
that we had a case of this formidable malady to deal with, but the time 
for the appearance of the variolous eruption passed by without its oc- 
currence. Death took place on the fifth day. The temperature during 
the sickness was high, though the record of it has been mislaid. For- 
tunately, such severe hemorrhagic cases, which are l necessarily fatal, 
are rare. 

Complications and Sequels. — Scarlet fever, if its type be severe, 
is in itself dangerous to life. Many, as we have seen, perish from its 
direct effects when it produces profound blood-poisoning. But, while 
the ordinary epidemics of this malady are necessarily attended by a large 
mortality from the virulence and depressing effect of the specific princi- 
ple, unfortunately, of all the diseases of modern times, scarlatina ranks 
first as regards the number and gravity of its complications and sequence, 
so that nearly or quite as many perish from these as from the direct 
effects of the poison. 

Nervous accidents occur chiefly at two periods — to wit, in the first 
days, when they are due to the severity and malignancy of the malady 
and to the impressible nervous temperament of the child, and in the de- 



COMPLICATIONS AND SEQUELJ. 221 

clining stage, or after the termination of the fever, when they occur from 
uraemia. If the type be malignant, delirium, jactitation, profound stu- 
por, and convulsions frequently occur on the first and second days ; and 
these are symptoms which properly excite the utmost alarm and demand 
all the resources of our art, since they indicate a. form of the disease 
which frequently ends in speedy death. The eyes have a dull or wild 
expression, the conjunctiva is suffused, the heat of surface pungent, the 
pulse rapid and compressible or feeble, rising above 150, even to 200, 
per minute, and the temperature is always elevated to a degree that in- 
volves danger, the thermometer not infrequently indicating 105° or 106°. 
But this severe form of scarlet fever, attended by so great elevation of 
temperature, is much less dangerous than in former times, even though 
it be complicated by delirium and convulsions, since we no longer hes- 
itate to reduce bodily heat, when excessive, by the free use of cold baths, 
and have discovered potent agents in the bromides and chloral for con- 
trolling convulsions. Nevertheless, not a few perish in the commence- 
ment of scarlet fever with predominating cerebral symptoms, as delirium 
or eclampsia, followed by coma, under the best possible treatment. 
Sometimes the symptoms have closely simulated those of acute menin- 
gitis, and if the rash have been delayed and the sore throat is as yet 
slight, the physician may suspect that he is dealing with this disease; 
but autopsies in such cases show no inflammatory lesions, but only con- 
gestion of the cerebral- and meningeal vessels. 

As is stated in a preceding page, in every case of normal scarlet fever 
inflammation of the faucial surface is present, as indicated by redness, 
tenderness, and increased secretion of mucus or muco-pus. It precedes 
the efflorescence on the skin, and is announced by pain in swallowing 
and on pressure with the fingers behind and below the angles of the jaw. 
In that form of scarlet fever which has been designated anginose the 
pharyngitis is severe, and is a prominent element in the malady, the 
uvula, the pillars of the fauces, and the faucial surface in general being 
infiltrated and swollen. Nevertheless, this inflammation, with the 
accompanying tumefaction, is properly a part of the disease, rather 
than a complication, if it abate with the subsidence of the scarlet fever 
or begin to abate soon after, and if it produce but slight destructive 
change in the tissue of the neck. The secretions from the fauces may 
be foul and offensive ; even superficial ulcerations or gangrene may 
occur upon the faucial surface, causing it to present a dark brown or 
jagged appearance, and the tissues of the neck may be infiltrated to a 
certain extent, and we designate the disease a form of scarlet fever 
under the title anginose. But when this condition is greatly aggra- 
vated, so that extensive infiltration and swelling of the tissues of the 
neck occur, with an amount of ulceration or gangrene which in itself 
involves danger, continuing after the primary disease abates, prolonging 
the fever and reducing the strength, it is proper to regard the state of 
the throat as a complication. In addition to the pharyngitis, which is 
severe as described above, the sides of the neck around the angles of 
the jaw become swollen, hard, and tender. The inflammation has been 
propagated to the deeper structures of the neck. Poisonous substances, 
the result of decomposition or vitiated secretions, traverse the lymphatic 



222 SCARLET FEVER. 

vessels from the faucial surface, and, being intercepted in the lymphatic 
glands, cause adenitis, and the inflammation extends from the glands to 
the adjacent connective tissue, which becomes hard, tender, swollen, and 
infiltrated with inflammatory products. This tumefaction sometimes 
begins by the second or third day, but it is usually about the close of 
the first week or in the beginning of the second week that it becomes so 
considerable as to constitute a source of danger and anxiety. It is in 
most cases bilateral, though one side may begin to swell before the 
other and remain larger throughout. 

In severe cases of this complication the tumefaction extends from ear 
to ear, filling up the space below and around the angles of the jaw and 
under the chin. Not only is deglutition difficult, but it is difficult to 
open the mouth sufficiently to inspect the fauces, and attempts to do so 
cause much pain. The lymphatic glands, which lie in the inflamed 
area and participate in the inflammation, are greatly enlarged by hyper- 
plasia, the round granular lymph cells multiplying so abundantly that 
the glands increase to many times their normal size. Most of the 
tumefaction is, however, due to extension of the inflammation to the 
connective tissue of the neck. The cellulitis, which resembles that 
occurring in other conditions, is attended by distention of the capil- 
laries, the abundant formation of young round cells, and transudation 
of serum (Billroth). A moderate amount of tumefaction may disappear 
by resolution, but if it be considerable it seldom abates in this way, but 
by the tedious and exhausting process of suppuration or gangrene. If 
the swelling at its most prominent point present a reddish hue, all hope 
of producing resolution must be abandoned ; it cannot be effected by 
any medicine or appliance within the resources of our art. The 
abscess which forms is likely to be diffuse, so as to involve danger of 
pyaemia, unless it be soon opened and properly washed out. With the 
discharge of the pus the swelling gradually softens and declines. In 
other cases gangrene results. The vessels in the inflamed part are com- 
pressed by the inflammatory products, so that they no longer convey the 
blood which is required for tbe purpose of nutrition. It is a law of 
the economy that whenever the circulation ceases, the tissues which 
receive their nutritive supply through the obstructed vessels lose their 
vitality. Hence gangrene occurs in all that portion of the swelling in 
which the circulation is arrested. The skin over it peels off, the dead 
tissue underneath is brown or dark, and soon, if life be prolonged, the 
slough begins to separate. The prognosis as regards this complication 
depends largely on the size of the slough. If it be large, death will 
probably result, since the strength of the system is already reduced by 
the primary disease, and the reparative process will necessarily be slow, 
while abundant suppuration tends to increase the exhaustion. In some 
of the worst cases of cervical gangrene which I have seen the slough 
has laid bare the muscles and vessels of the neck, producing in one 
case a cavity or excavation sufficiently large to admit a hen's egg. 
Often the slough extends under the skin, so that the deepest recesses 
of the cavity are not visible, and occasionally in cases which have ended 
fatally in my practice severe hemorrhage occurred from the concealed 
vessels. If the ulcerative or gangrenous process extend so deeply into 



COMPLICATIONS AND SEQUELJS. 223 

the tissues of the neck that hemorrhages occur, death is the common 
result ; but if the destructive action be of moderate extent and other 
conditions favorable, we may expect recovery through cicatrization, 
with perhaps some deformity by contraction of the cicatrix. 

When the inflammation of the connective tissue of the neck is exten- 
sive, involving both the lateral and anterior regions of the neck, the 
patient is in a perilous state. The cellulitis, when extensive and accom- 
panied by much swelling, may produce oedema of the glottis, may 
obstruct respiration by compressing the air-passages or the laryngeal 
nerves, may cause compression of the jugular veins, and thus give rise 
to dangerous cerebral symptoms, or may lay bare and injure important 
muscles and nerves, as we have seen. If the ulceration or gangrene 
be extensive, and death do not occur by hemorrhage from arterial or 
venous twigs, septic poisoning may occur, increasing still more the fatal 
nature of the malady. 

Some cases of this complication are melancholy in the extreme, as 
one related by Cremen, in which ulceration of the pharynx occurred, 
allowing the escape of food and preventing deglutition. In severe scar- 
latinous pharyngitis the inflammation sometimes extends along the 
Eustachian tube, causing its occlusion. This accident will be con- 
sidered when we treat of otitis media, another grave complication. It 
often also extends into the nares, causing catarrh of the Schneiderian 
mucous membrane, with discharge of muco-pus from this surface. Not 
infrequently ulceration or gangrene occurs in the faucial surface, pro- 
ducing; more or less destruction of tissue and forming excavations which 
connect with the throat, while the cutaneous surface retains its integrity 
and is not even reddened. The following case shows how grave the 
complication which we are now considering sometimes is when the ex- 
ternal surface of the neck is not involved, and how the inflammation 
by extension outward from the fauces may involve the middle ear. 

Case 1. — Annie K , aged two and a half years, and inmate of 

the New York Foundling Asylum, was well, except an eczema of the 
scalp, until the night of April 3, 1882, when she was attacked with vomit- 
ing and diarrhoea. She was feverish and drowsy, and at 2 p. M. on the 
4th the scarlatinous efflorescence appeared upon her neck, body, and 
lower extremities ; tongue coated ; pharynx red ; temperature (axillary) 
103° ; pulse 160. The symptoms and aspect indicated a grave form of 
the malady, and the usual sustaining treatment was ordered. On April 
5th the temperature was 102°, pulse 144, tongue less coated, eruption 
fading, less stupor, no albumen in urine. April 6th, morning temperature 
102°, pulse 160; passed a restless night; stools thin and too frequent; 
has grayish patches in the throat ; p. M. temperature 103^°, pulse 150. 
April 7th, the diarrhoea continues, and she has a copious muco-purulent 
discharge from the nostrils ; p. m. temperature 103f°, pulse 160. April 
10th, the temperature has continued at about 103° ; the patient is very 
sick, with a constant foul-smelling discharge from the nostrils; breath 
very offensive ; temperature 103.5°, pulse about 180. April 12th, general 
appearance a little better, but the posterior surface of the fauces is com- 
pletely covered by a thick pseudo-membrane ; had four loose stools last 
night ; temperature and pulse the same as at last record ; a dark, offen- 



224 SCARLET FEVER. 

sive, and jagged coating over the fauces, and a dark, foul discharge from 
the nostrils, as before; examination of the chest negative. April 14th, 
is much prostrated; temperature 104.5°, pulse rapid and weak; respira- 
tion noisy, diminished resonance over lower two thirds of left side of 
chest ; ulcers upon the mouth and tongue ; fauces red and ulcerated. 
April 17th, pulse 150, temperature 100.5 J ; general appearance somewhat 
better, but the diarrhoea continues, and patches of a diphtheritic char- 
acter have appeared upon the lips ; moist rales- in left side of chest. The 
symptoms continued nearly the same until April 23d, when she died. A 
dull percussion sound and distinct bronchial respiration were observed in 
the left scapular region during the last days of her life. 

Autopsy nine hours after death by the curator, Dr. W. P. Northrup : 
Body well nourished ; the tissues have a jaundiced hue ; lips sore ; on 
turning the head to one side pus runs from the left ear and dirty muco- 
pus from the mouth. Brain normal ; on opening the petrous portion of 
the left temporal bone the middle ear is found full of pus, which com- 
municated freely with the external ear through a perforated membrana 
tympani ; the Eustachian tube cannot be traced in the sloughy tissue, 
and a passage filled with pus extends from the ear to the fauces ; opposite 
the greater cornua of the hyoid bone are two deep ulcers, each having 
about the diameter of a ten-cent piece, with sloughy and offensive base 
and sides ; the left ulcer communicates by a ragged and wide sinus with 
a dark and sloughy cavity of about four drachms capacity ; this cavity is 
located in the neck under the angle of the jaw, apparently occupying the 
site of a disintegrated gland, and it opens upon the surface of the fauces. 
The surface of the larynx has a dusky, dirty appearance, sprinkled with 
little cheesy-looking spots, and covered by a dirty, foul-appearing liquid, 
as if some of the ichorous pus had escaped into it from the neck ; about 
one and a half inches below the vocal chords there is an unmistakable 
pseudo -membrane; below this, near the bifurcation, the trachea has a 
bright-red color, as if a pseudo-membrane had been peeled from it, 
leaving the surface raw. The detachment of a pseudo-membrane from 
this part, if it did occur, must have been ante-mortem, for the organ had 
been carefully handled in making the autopsy. Between the apex of the 
left lung and the median line the tissues of the neck, dissected upward, 
are found indurated, yellow, and giving an offensive odor, showing that 
the cervical cellulitis had extended downward further than usual. The 
bronchial glands have undergone hyperplasia, being enlarged and hard. 
The right lung is normal ; about one -half of the left lower lobe is con- 
solidated, and when cut is found to be gangrenous 'and offensive. The 
liver is apparently somewhat enlarged ; spleen normal in size ; gastric 
mucous membrane has a congested appearance and is covered with 
mucus ; mesenteric glands enlarged, pale, and firm ; Peyer's patches 
swollen and pale ; at lower end of ileum some pigmentation of these 
glands ; in large intestine the solitary glands are enlarged, and a few of 
them pigmented ; kidneys pale, cortex thickened, and markings indis- 
tinct. Microscopical Examination. — In the pia mater perhaps a little 
increase of cells ; meninges of brain otherwise normal. The trachea 
shows well-marked diphtheritic inflammation; it contains a film of 
pseudo-membrane ; evidences of inflammation occur also upon the laryn- 
geal surface, though less marked than in the trachea. The solidified 
portion of the lung exhibits the ordinary lesions of broncho-pneumonia, 
with some interstitial change. In the kidneys we find parenchymatous 
nephritis, with some cell-growth in the Malpighian bodies. 



COMPLICATIONS AXD SEQUELJE. 225 

The above case has been related at length, not only because it shows 
how severe and destructive the inflammation of the throat, extending 
into the tissues of the neck, sometimes is, but because four other com- 
plications or sequelae were also present — to wit, otitis media, diphtheria, 
nephritis, and pneumonia. We see how formidable a disease scarlet 
fever sometimes is when attended by the inflammations to which it so 
frequently gives rise, for a child older and stronger than this, if thus 
affected, would inevitably have perished with the best possible treatment. 

In localities where diphtheria is endemic, as in New York City and 
Paris, scarlet fever is often complicated by pseudo-membranous inflam- 
mation of the fauces and air-passages. In severe cases the Schneiderian 
as well as the faucial surface is covered with pseudo-membrane, so that 
it can be readily seen on inspecting the anterior nares. Occasionally, 
this exudation appears upon the laryngeal and tracheal surfaces, as in 
the case which I have related above and in others presently to be related, 
causing dangerous embarrassment of respiration. This complication 
sometimes begins almost at the commencement of scarlet fever, but in 
most instances it does not occur before the third or fourth day, and it 
sometimes does not appear till in the declining stage of the fever. When 
it begins, it intensifies the febrile movement and produces general aggra- 
vation of symptoms. 

The elaborate treatise by Sanne, of Paris, on diphtheria contains a 
chapter entitled " Secondary Diphtheria." In it the author says, what 
all who are familiar with diphtheria will agree to, that secondary diph- 
theria does not differ in nature from the primary form, and that it 
exhibits a tendency a to occupy the organs which are themselves the 
seat of the more pronounced local determinations of the primitive 

malady Diphtheria is seen in the course or sequel of numerous 

diseases. Some appear to have a special proclivity for engendering 
diphtheria ; these are specific maladies : measles, scarlet fever, per- 
tussis." Sanne' s statistics relating to the seat of scarlatinous diphthe- 
ritic exudation are as follows : 

Fauces alone attacked . 15 cases. 

Fauces with larynx attacked . . ... . . 4 " 

Fauces with nasal fossa attacked . . . . 8 " 

Fauces with larynx and nasal fossa attacked . . . 4 " 

Fauces with larynx and bronchi attacked . . . 1 " 

Fauces with nasal fossa and lips attacked . . . 1 " 

Fauces with lips and skin attacked ..... 1 u 

Fauces unaffected . . . . . . . 3 " 

Diphtheria generalized ....... 2 " 

Larynx only affected . . . . . . . 2 " 

Nasal fossa 1 " 

The opinion of so good an observer as Sanne, that when in scarlet fever, 
pseudo-membranous exudation appears upon the mucous surfaces which 
are the seat of scarlatinous inflammation, diphtheria has supervened, 
and not a croupous form of scarlatinous phlegmasia, carries with it 
great weight. 

Nevertheless, one of the most difficult problems which we have to 
deal with in certain cases is to distinguish diphtheritic from non-diph- 
theritic inflammation ; and I see no reason why the scarlatinous inflam- 

15 



226 SCARLET FEVER. 

mation when intense may not be sometimes membranous. We know 
that in some cases of dysentery a fibrinous exudation occurs upon the 
surface of the colon ; that in croupous pneumonia fibrin exudes into the 
bronchioles and alveoli of the lungs ; and that physicians in localities 
where there is no diphtheria meet, though at long intervals, cases which 
they designate croupous pharyngitis and laryngitis ; and it seems 
probable that the intense inflammation of anginose scarlatina some^ 
times produces the same exudation. Moreover, it is very difficult to 
distinguish in the swollen fauces between a membranous exudation and 
ulceration or superficial gangrene so common in malignant scarlet fever. 
The grayish-white surface, jagged and foul, may be the one or the other, 
an exudation or a sphacelus, and in certain instances it is impossible to 
discriminate between the two conditions at the bedside. 

Diphtheria complicating scarlet fever occasionally begins nearly simul- 
taneously with the latter. Henoch states that exceptionally he has 
observed suspicious patches upon the fauces before the appearance of 
the scarlatinous eruption upon the skin ; and he adds : " I have had 
repeated opportunities of observing this unusual beginning. In such. 
cases we must ask ourselves whether the first affection was really con- 
nected with the second, or whether the former was a true primary diph- 
theria, rapidly followed by scarlatina. This opinion is favored by the 
fact that I had only observed such cases in the hospital, in which infec- 
tion with various forms of contagion can scarcely be avoided." 

But usually it is not till the third or fourth day of scarlet fever that 
this complication begins. The patient has been progressing favorably 
with the fever, till on a certain day a marked aggravation of symptoms 
occurs. A higher temperature, more pungent heat, and the physiog- 
nomy of a more serious malady are present. On inspecting the fauces 
to discover the cause we observe a pellicle forming upon the tonsils 
and perhaps other portions of the faucial surface. Often the entire 
aspect of the case changes by the occurrence of this complication, a 
mild case of scarlet fever becoming grave and fatal in consequence. 
Thus in a case which I saw with Dr. Hardy, of New York, the mem- 
branous inflammation of diphtheria, commencing upon the fauces on 
the third day of scarlet fever, extended to the Scbneiderian membrane, 
and thence along the left lachrymal sac to the eyelids, producing redness 
and swelling along the side of the nose and upon the' cheek like that of 
erysipelas. A thick diphtheritic pellicle occurred upon the under surface 
of each eyelid on the left side, with great tumefaction of both lids, gan- 
grene of the cornea, and destruction of the eye. The case soon ended 
fatally. 

A pellicular exudation sometimes occurs in the larynx and trachea 
during the course of scarlet fever, as a thin film, rendering the respira- 
tion noisy, but the development of a thick and firm pseudo-membrane, 
so as to imperil the life of the patient from the stenosis in the air- 
passages, has been much less frequent in my practice than it is in 
primary diphtheria and in diphtheria complicating measles or pertussis. 
The following were cases of this severe complication occurring in a 
recent epidemic in the New York Foundling Asylum. In these cases 
the respiration was noisy, but the obstruction to breathing was apparently 



COMPLICATIONS AND SEQUELS. 227 

due to infiltration and swelling around the aperture of the glottis, more 
than to the pseudo-membrane, which the autopsies showed to be present. 

Case 2. — A child aged three and a half years, who previously had 
symptoms of mild catarrhal croup, with moderate redness of the fauces, 
sickened with scarlet fever on Oct. 1, 1882, the rash being profuse and 
soon covering nearly the entire body. The axillary temperature was 
103°, pulse 140 ; slight stridor in breathing and some cough; fauces very 
red, but free from membrane. Oct. 2d, restless, sleeping but little ; has 
vomited four times. Oct. 3d, temp. 103.5°, pulse 120; fauces much 
swollen; still vomiting; rash abundant. 4 p.m., temp. 104.3°, pulse 
128; tongue clean; some discharge from nares; urine not albuminous, 
but its quantity diminished. Oct. 4th, aspect that of very severe sick- 
ness ; profuse discharge from nostrils ; fauces of a deep red color, and a 
pseudo-membrane over tonsils and uvula; tumefaction along the sides 
of the neck ; temp. 104°, pulse 140 ; breathing moderately striclulous ; 
urine is passed more freely than yesterday; evening temp. 105°. Oct. 
6th, croupy symptoms more marked; tonsils and uvula greatly swollen, 
so that the fauces are almost occluded ; temp. 103.5° breathing difficult, 
but apparently sufficient oxygen is received; profuse nasal discharge, 
and other symptoms as before. About 1.30 P. m. he was raised to take 
some milk, and suddenly became asphyxiated. His face was dusky, the 
eyes protruded, and he voided urine and feces. Dr. Swift, who attended 
the child, and to whom I am indebted for this history, immediately per- 
formed tracheotomy, which gave temporary relief by the expulsion of a 
considerable quantity of pseudo-membrane through the opening. On 
the following day the respiration again became obstructed at some point 
below the canula, so that it could not be removed ; the features grew 
livid, and death occurred in convulsions twenty-six hours after the 
tracheotomy. 

The autopsy was made by Dr. "W. P. Northrup, curator of the Asylum, 
who found the pharynx covered by a membrane which was traced to the 
posterior nares ; larynx, trachea, and bronchial tubes as far as the third 
divisions, covered with membrane ; portions of the tracheal surface de- 
nuded, and the mucous membrane underneath of a bright red color and 
smooth. 

Case 3. — Katie, aged six and a third years, was returned to the Asylum 
on Nov. 18th. Three days later (Nov. 21st) she had sore throat, red- 
dened fauces, coated tongue, and a faint rash upon the neck, chest, and 
arms; eyes injected ; temp. 102°. In the afternoon temp. 103° ; eruption 
still faint. Nov. 22d, temp. 103.5° ; an eruption on chest, abdomen, arms, 
and legs in patches. Evening, temp. 104° ; voice clear. Nov. 23d, temp. 
103.5°; tongue red; fauces deeply reddened, but without any visible 
pseudo-membrane; the scarlatinous eruption has appeared over a consid- 
erable part of the surface. On the 24th a pseudo-membrane occurred 
over the tonsils and adjacent faucial surface; her respiration became 
labored, and death took place from dyspnoea at 11 p. m. 

Autopsy : Naso-pharynx covered by a thick fibro-purulent membrane. 
Larynx contains a well-marked pseudo-membrane, but not continuous. 
Trachea covered by a pseudo-membrane, continuous over most of its sur- 
face, but in places broken and flaky. Where it is detached the mucous 
membrane is seen underneath, dusky and deeply injected. At the root 
of the lungs the pseudo-membrane can be traced along the tubes about 
an inch in all directions. Nothing noteworthy in the other lesions. 



228 SCARLET FEVER. 

In a fourth case of scarlet fever, in which death occurred after an ill- 
ness of three weeks and from gradually increasing dyspnoea, it is stated 
in the records of the autopsy that the larynx was free from a pseudo- 
membrane ; a thin film extended over a considerable part of the trachea. 

Coryza frequently commences at or about the time of the pharyn- 
gitis. The inflammation of the Schneiderian membrane is continuous 
posteriorly with that of the fauces, and is announced by redness and 
swelling, inability to breathe freely through the nostrils, and an irri- 
tating ichorous discharge. Simple coryza in itself involves little danger, 
though it is an unpleasant complication, and in the nursing infant it may 
interfere with suckling. Diphtheritic coryza, on the other hand, which 
is frequently present when diphtheria complicates scarlet fever, involves 
danger, since it is apt to cause ulcerations, hemorrhages, and septic 
poisoning. When the local symptoms are unusually severe and the dis- 
charge abundant, it is probable that inflammation has in some cases 
extended to the antrum of Highmore. 

Inflammation of the middle ear is another unpleasant and not infre- 
quent complication. It is due to extension of the catarrh from the 
pharynx along the Eustachian tube to the tympanum. In a consid- 
erable proportion of cases of otitis media this tube is occluded by the 
infiltration and swelling of its mucous membrane, so that the muco-pus 
escapes with difficulty or is retained. Hence severe earache, an increase 
of the febrile movement, and outward bulging of the membrana tym- 
pani occur. Sometimes headache or other cerebral symptoms arise, 
probably from the fact that the meningeal artery, which supplies the 
meninges, is connected by anastomosing branches with the tympanum. 
In one of the cases related above it will be recollected that the ulcera- 
tion and abscess extended from the fauces to the middle ear, the entire 
Eustachian tube having disappeared in the ulcerative process. 

Frequently, the otitis escapes detection, its symptoms being masked 
or obscured by the general disease, until the membrana tympani is 
perforated and otorrhoea begins; but by careful examination the nature 
of the complication can usually be ascertained before the ear is injured 
to this extent, for a patient too young to speak will often press with 
the fingers against the painful ear or lie with the ear pressed upon the 
pillow, evidently having an increase of suffering if placed in any other 
position. One old enough to speak and in proper mental condition 
makes known the earache as soon as it occurs. 

The mucous membrane of the tympanum, red and swollen from 
inflammation, secretes muco-pus abundantly ; and this, pent up in the 
cavity, must obtain an exit before relief occurs. It is well if the secre- 
tion escape, though with difficulty, down the Eustachian tube. The 
destructive action of the pus upon the delicate structure of the ear is 
often such that, within a few days, irreparable harm is done and more 
or less deafness results. Relief can occur, if the Eustachian tube 
remain closed, only by perforation of the membrane and the discharge 
of the secretions into the external meatus. When this takes place the 
inflammation in the most favorable cases gradually abates, the aperture 
in the drum closes, and the integrity of the auditory apparatus is pre- 
served. In severe cases the mastoid cells participating in the inflam- 



COMPLICATIONS AXD SEQUELAE. 229 

mation become filled with muco-pus and tender to the touch, and often 
the collateral oedema causes tumefaction and narrowing of the external 
ear, which subside with the discharge of pus from the tympanum. 

Unfortunately, there is for many a more melancholy history — a more 
destructive inflammation, involving permanent impairment or total loss 
of hearing. This is especially apt to occur in strumous or feeble 
children. All grades of inflammation and destructive action occur in 
different cases. The perforation in the drum-membrane may be large 
or the membrane may be completely destroyed, and the detached ossicles 
escape one by one into the external meatus, and in a few instances, 
fortunately rare, this occurs in both ears, producing complete and per- 
manent deafness. In my own practice this has never occurred, but I 
have met one or two adults who were totally deaf from this cause. 

The mucous membrane which lines the bony wall of the middle ear 
has the function of the periosteum, and therefore, when inflamed and 
subjected to pressure, is liable to ulcerate. As in other parts of the 
skeleton under similar conditions, superficial caries or necrosis of the 
underlying bone is apt to occur. The carious or necrotic process may 
extend to the mastoid cells. An offensive otorrhoea, continuing for 
months or years, indicates the persistence of this pathological state of 
the tympanum, which is rendered so obstinate by the presence of dead 
bone. A moment's survey of the anatomical relations of the middle ear 
shows the danger to which these patients are liable. A thin bony 
septum, perforated with bloodvessels and sometimes containing con- 
genital apertures, separates the tympanum from the cranial cavity 
above. Posteriorly lie the mastoid cells, connected with the tympanum 
by one large and several small apertures. Anteriorly is the commence- 
ment of the Eustachian tube, and in close proximity to the tympanum 
lies the carotid canal, and at one point also the superior petrosal sinus. 
Virchow has shown how inflammation extending from the ear in otitis 
media sometimes produces such compression of the veins or sinuses by 
the swelling from the infiltration and exudation that the circulation is 
arrested, and the fibrin contained in the blood of these vessels is pre- 
cipitated, forming thrombi, with the most disastrous effect upon the 
individual. Pus may also burrow in the interstices of the bone, causing 
great pain, or the pent-up secretions, having no outlet for escape, may 
in time undergo caseous degeneration, producing the conditions in which 
tuberculosis so often originates. 

Death not infrequently occurs in chronic otitis media in another way. 
The otorrhoea, after months or years, suddenly ceases, the child com- 
plains of constant severe headache and is feverish, and the case ends in 
coma, preceded perhaps by convulsions. Meningitis has occurred, pro- 
duced by extension of the inflammation through the thin bony septum 
which divides the tympanum from the cranial cavity, and at the autopsy 
hyperemia of the meninges, fibrin, pus, perhaps softening of the brain 
and an abscess, are found in the portion of the encephalon adjacent to 
the tympanum. Therefore, otitis media, though it often ends favorably, 
is in many patients an obstinate, dangerous, and even fatal sequel of 
scarlet fever. 

The complication known as scarlatinous rheumatism is regarded by 



230 SCARLET FEVER. 

some as a synovitis, but its symptoms, especially its shifting from joint 
to joint, seem to ally it to the rheumatic affections. In some epi- 
demics it is common. It usually begins toward the close of the first 
week or in the second week, and its common seat is in the ankle, pha- 
langeal, and wrist joints. It is attended by very little swelling in most 
patients, though the joints are tender and painful on pressure. It does 
not seem to retard convalescence materially, but it produces suffering 
and involves danger as regards the heart. It subsides in a few days 
with the ordinary treatment of acute rheumatism, and even without 
special treatment, the chief danger being that, as in idiopathic rheuma- 
tism, endocarditis may arise, with permanent crippling of the valves. 
The following was a case of valvular disease having this origin. It 
occurred in my practice. 

Case 5. — Freddy M., aged four years, sickened with scarlet fever 
March 6, 1879. The usual vomiting occurred on the first day, and the 
temperature was 104°. The case progressed favorably till March 14, 
when he complained of pain in both wrists, both ankles, and both knees. 
On March 17th the general condition was good, the urine contained no 
albumen, and apparently few urates, but he still had pain in the joints of 
the upper and lower extremities and in the back ; pulse 140, temperature 
103° ; breathes with a slight moan ; urates in the urine, but no albumen. 
A distinct mitral regurgitant murmur is now heard for the first time. 
Under the use of salicylate of sodium the pain in the joints soon ceased, 
but the mitral murmur is permanent. 

The following prescription is for a child of five years : 

R. — 01. gaultherise fgj. 

Sodii salicylat. ....... sjiij. 

Syrupi f^ij. 

Aquse . . . fjiv- — Misce, 

Sig. — Give one teaspoonful every four hours in water. 

Of the serous inflammations complicating scarlet fever, pericarditis 
has been, according to Rilliet and Barthez, most frequently observed. 
In this country it is probably more common than is usually supposed, 
but it is less frequently detected than pleuritis, the symptoms of which 
are more conspicuous. 

The following case, which occurred in my practice, was an example of 
this complication: 

Case 6. — C , girl, aged five years and ten months, sickened with 

severe scarlet fever on April 4th. Was delirious; pulse 158 ; had vomit- 
ing and constipation. April 10th, pulse varies from 124 to 153, no 
delirium; a considerable quantity of urates in the urine. April 11th, 
has to-day, for the first time, severe pain in the epigastrium, with tender- 
ness and moderate distention. Otherwise symptoms favorable, but severe ; 
pulse 140 ; respiration moderately accelerated, and vesicular in every 
part of the chest. From this dale the symptoms continued about the 
same till April 14th, when the dyspnoea became more marked, and the 
action of the heart rapid and tumultuous. The epigastric pain, disten- 
tion, and tenderness continued ; the percussion sound was dull over the 
lower part of the chest ; the dyspnoea became rapidly worse, although the 
pulse had considerable volume ; and at 5 p. m. death occurred. At the 



COMPLICATIONS AND SEQUELJE. 231 

autopsy about one ounce of turbid serum, with a soft deposit of fibrin, 
was found in the pericardium. Each pleural cavity contained from six 
to eight ounces of transparent serum, and both lungs were readily inflated, 
except a little of the posterior portions of both lower lobes ; no fibrinous 
exudation over the lungs. The liver extended four inches below the 
margin of the ribs, and upon its convex surface in the epigastrium, corre- 
sponding with the seat of the pain, was a rough patch of fibrin about one 
and a half inches in diameter. The bronchial mucous membrane was 
moderately injected, as was also that of the colon, and the kidneys appeared 
hyperaemic. 

Among the serous inflammations which complicate or follow scarlet 
fever, pleuritis is one of the most important. It usually begins in the 
desquamative stage, and is frequently suppurative on account of the 
feeble state of the patient when it commences. It has. in my practice, 
been tedious, as all empyemas are, and it does not differ in its clinical 
history from the idiopathic disease. I have met cases of scarlatinous 
empyema in which, from opposition of the family or for other reasons, 
thoracentesis was not performed, and death occurred; others in which 
this operation effected a cure, and one at least in which the patient 
recovered by escape of pus through a bronchial tube and its expectora- 
tion. The pleuritis is seldom latent, or so masked by the symptoms of 
the general disease that it is liable to be overlooked. On the other 
hand, the cough, embarrassment of respiration, and pain referred to the 
affected side render diagnosis easy. 

Dilatation of the heart is common in grave cases of scarlet fever, 
such cases as are properly termed malignant. It is indicated by a feeble 
and quick pulse. Acute infectious maladies, especially those of a 
malignant type and accompanied by high febrile movement, are very 
liable to cause parenchymatous degenerations in organs, prominent among 
which is granulo-fatty degeneration of the muscular fibres of the heart. 
This weakens very much the contractile power of these fibres. But 
early in malignant cases, probably before the muscular fibres are 
damaged, the contractile power of the heart is feeble from impaired 
innervation, the result of the general weakness. Hence this organ, 
when weakened by structural change and insufficiently stimulated through 
diminished innervation, may not fully empty itself during the systole, 
and consequently it becomes dilated. Dilatation of the heart and im- 
perfect contraction of its auricular and ventricular walls facilitate the 
formation of clots in the cavities of the heart ; and this appears to be 
the immediate cause of death in not a few instances. An ante-mortem 
clot occurring in any of the cavities of the heart necessarily seriously 
obstructs the circulation, unless it be of small size. Hence the dys- 
pnoea, which may occur suddenly, and the change of pulse to one of 
marked feebleness and frequency. Large, firm white clots are most 
frequently found in the right cavities. They interlace with the chordae 
tendineae, lie even within the auriculo-ventricular opening, and send 
prolongations into the pulmonary artery and the cavae. Associated 
with the white clots are dark, soft clots and fluid blood. The left 
cavities may be contracted and empty, or they may contain dark, soft 
clots or white ante-mortem clots. Clots in the left ventricle are some- 



232 SCARLET FEVER. 

times prolonged into the aorta as far as the brachiocephalic branches, 
while those in the left auricle may extend to the pulmonary veins. 
If dilatation of the heart be so great that clots form in its cavities, 
speedy death is probable. Sometimes a patient passes through scarlet 
fever and appears in a fair way to recover, when he succumbs to some 
exhausting sequel distinct from the heart, and at the autopsy the heart 
is found dilated and containing whitish clots, which are probably ante- 
mortem, and which hastened death by obstructing the circulation. Un- 
der such circumstances this state of the heart is attributable in great 
measure to the complication which has weakened its contractile power. 

The following was a case in point. It occurred in the New York 
Foundling Asylum : 

Case 7. — R. A., aged three years, had scarlet fever, beginning March 
23, 1882. The symptoms were favorable at first, but serious complications 
and sequelae occurred, which were fatal. The record of Ajoril 18th reads : 
"Appears well nourished, but is anaemic; has otorrhoea; no oedema; 
skin desquamating ; dulness on percussion over upper third of right side 
of chest, anteriorly and posteriorly ; mucous rales and rude breathing 
over same area ; fine rales posteriorly over lower part of left side of chest ; 
pulse 160, respiration 68, temp. 101-f°." April 20th, is feeble and takes 
nutriment with difficulty ; tongue thickly coated ; pulse 160, respiration 
68, temp. lOlf °. April 26th, condition about the same as at last record, 
but he is evidently weaker ; the lips are ulcerated and fauces still swollen. 
May 2d, cannot speak distinctly ; a brownish, foul-smelling secretion 
lodges on the spoon used in depressing the tongue ; left side of face 
swollen. On the following night eight convulsions occurred, attended by 
orthopnoea, and mucous rales in the chest from pulmonary oedema. 
Diarrhoea sujoervened and the patient died about midnight. 

Autopsy : Body moderately wasted and very white, several dark blue 
spots on scalp and face from hemorrhages underneath. A careful examina- 
tion showed the presence of broncho-pneumonia in each lung, with consid- 
erable infiltration of the walls of the bronchi, and cylindrical dilatation of 
many of them ; cavities of the heart dilated, so that this organ appears much 
enlarged, and its shape approaches the globular ; its apex is rounded or 
obtuse ; transverse diameter of the right ventricle, when its walls were 
open and drawn apart, was three and one-quarter inches ; that of the left 
ventricle three and a half inches. Similar measurements of the heart of 
another child of about -the same age, believed to be normal, were about 
one inch less in each direction. All the cavities contain white firm clots 
along with soft dark clots. Lesions observed in other organs were care- 
fully noted, some of which were serious ; but the immediate cause of death 
appeared to be imperfect contraction of the heart, and the formation of 
clots in its cavities. 

There can be little doubt that nephritis in its milder form is much 
more common than was formerly supposed. A few years since little 
attention was given by a large proportion of physicians to the state of 
the kidneys, and the urine was not examined till dropsy made its ap- 
pearance, which only occurs in the more severe forms of nephritis and 
is a late symptom. It is now known that catarrh of the renal tubes fre- 
quently occurs in a mild form early in scarlet fever, without causing 
albuminuria, dropsy, or any notable symptom. It may produce a smoky 



COMPLICATIONS AND SEQUELS. 233 

color of the urine, and the appearance in it of granular epithelial cells, 
with an increase of mucus, but no albumen. With careful treatment 
and no exposure to cold, the renal catarrh abates with the decline of the 
scarlet fever. It is scarcely severe enough to merit the name desquama- 
tive, tubal, or parenchymatous nephritis, though it is a mild form of the 
same pathological state. Steiner states, as the result of many careful 
examinations of cases, that hypersemia of the kidneys was always pre- 
sent in those who died early in scarlet fever, and that in a certain pro- 
portion of these cases catarrh of the renal tubules was present in 
addition to the congestion. Even in some who died on the second or 
third day he found cloudiness of the epithelium in the renal tubes, 
although the urine had not indicated such a change. The opinion has 
even been expressed that catarrh of the renal tubes is as common in 
scarlet fever as that of the bronchial tubes in measles ; that is, it is a 
uniform element in the disease ; but this appears to be an exaggerated 
statement, for others have failed to find any evidence of renal catarrh 
in certain cases. 

The nephritis which gives rise to symptoms and therefore interests 
the practitioner, commonly begins in the declining period of scarlet 
fever or during the desquamative stage, and is in many instances plainly 
attributable to exposure to cold or to currents of air. It originates 
either during this period, or if it have previously existed as a mild renal 
catarrh, it now becomes aggravated. Dropsy, which always attracts at- 
tention, does not occur till the nephritis has continued for some time. 

Why nephritis, with the subsequent dropsy, so frequently occurs after 
scarlet fever is not fully understood. Rilliet and Barthez attribute it 
to disturbance of the function of the skin. The fact has long been 
observed that the kidneys become affected nearly if not quite as fre- 
quently after mild as severe cases. Indeed, the chief danger in mild 
cases, when the patients are but a short time in bed and are soon allowed 
to go about, is from the nephritis. Chilling the surface and checking 
cutaneous transpiration appear to be the immediate cause of this inflam- 
mation in a considerable proportion of cases. Therefore, severe attacks of 
scarlet fever with abundant rash and desquamation, which require the 
patient to be kept in bed the proper time and in a warm room two or 
three weeks, appear to be less frequently followed by this renal disease 
than are milder cases which are more carelessly treated, 

The most thorough and minute microscopic examinations of the state 
of the kidneys in scarlet fever which have come to my notice were 
those by E. Klein, published in the Loud. Path. Soc. Trans. , and illus- 
trated by microscopic drawings. It appears from these examinations 
that the changes in the kidneys are complex, among which we recognize 
both those of parenchymatous or desquamative nephritis and interstitial 
nephritis; but we would infer that the interstitial nephritis is mild in 
degree and quite subordinate, or else confined to portions of the organ, 
from the fact that so many permanently and fully recover. The follow- 
ing is a resume of Klein's examinations in twenty -three cases : We con- 
clude from these microscopic researches that the anatomical changes of 
both parenchymatous and interstitial nephritis are commonly present in 
greater or less degree in cases of scarlet fever. If they are mild or con- 



234 SCARLET FEVER. 

fined to portions of the kidneys, no symptoms occur; but if they are 
sufficient in extent or degree to impair the function of these organs, then 
symptoms, as albuminuria, diminution of urine, etc., appear. 

1. Parenchymatous Nephritis, Proliferation of Nuclei, Hyaline De- 
generation of Arterioles. The Grlomerulo-nephritis of Klebs. — Klein 
found increase of nuclei (probably epithelial) upon the glomeruli and 
hyaline degeneration of the intima of minute arteries, especially marked 
in the afferent arterioles of the Malpighian bodies. The intima of these 
vessels was in places so swollen as to resemble cylindrical or spindle- 
shaped hyaline masses, and cause narrowing of the lumina of the vessels 
in which this degeneration occurred. Klein observed in some specimens 
so great hyaline degeneration of the capillaries of the Malpighian bodies 
that circulation through them was obstructed. In the more advanced or 
protracted cases this hyaline substance in the glomeruli began to assume 
a fibrous appearance. Bowman's capsule was considerably thickened. 
This hyaline degeneration of the Malpighian bodies Klein discovered in 
the earliest cases which fell under his observation. 

Also in the earliest cases the multiplication or germination of the 
nuclei of the muscular coat of the arterioles was observed, with a corre- 
sponding increase in the thickness of the walls of these vessels. This 
change in the muscular element was found in the arterioles in different 
parts of the kidney, but it was most conspicuous in these vessels at their 
point of entrance into the Malpighian bodies; and it was distinctly no- 
ticed in other arterioles, both in the cortex and in the base of the 
pyramids. 

In the glandular portion of the kidneys other anatomical alterations 
were observed, indicating parenchymatous nephritis. There were swell- 
ing of the epithelial lining of the convoluted tubes; multiplication of 
nuclei of epithelial cells especially in ascending tubules, which lay close 
to the afferent arterioles of Malpighian corpuscles ; granular matter, and 
even blood, in the cavity of Bowman's capsule and in the convoluted 
tubes; cloudy swelling and granular disintegration of epithelium in 
some parts of the convoluted tubes ; detachment of epithelium from the 
membrane of larger ducts of the pyramids in some cases. These 
parenchymatous changes are already known to the profession through 
the observations and writings of Dickinson, Fenwick, Johnson, John 
Simon, and others. 

Klein, in commenting on the hyaline degeneration which he observed, 
states that Neelsen found the walls of the capillaries of the pia mater 
thickened, highly refractive, and of a lardaceous appearance in certain 
acute infectious maladies, as variola, typhoid fever, measles, and in one 
case of scarlet fever. 1 Usually, only a small portion of the capillaries 
were thus affected, most frequently at the point of division into branch- 
lets. In a few instances Neelsen noticed degeneration of arterioles 
extending a considerable distance, with fusion of the intima, media, and 
adventitia, and chemical examination showed that the substance pro- 
duced by this degeneration had similar properties to elastic tissue. 
Although the examinations by Neelsen relate to the pia mater, two of 

1 Archiv der Heilkunde, 1876. 



COMPLICATIONS AND SEQUELAE. 235 

his observations are especially interesting — -first, that the hyaline change 
affects chiefly vessels near their point of branching ; and, secondly, that 
the hyaline substance is of the nature of elastic tissue, for in the kidney 
in scarlatinous nephritis the arterioles undergo the change in question 
chiefly near their point of branching into the capillaries of the glome- 
rulus ; and the intima being the part which undergoes the hyaline 
change, it is probable, in the opinion of Klein, that the same substance 
is produced by the degeneration in walls of the vessels of the kidney 
which Neelsen observed in the pia mater, and therefore that it is of the 
nature of elastic tissue. 

This hyaline degeneration of the arterioles is also very marked in the 
spleen in scarlet fever; and in studying the minute anatomy of the 
intestines and spleen in typhoid fever, Klein has found the same degen- 
eration of the intima of the minute vessels. He believes that this 
hyaline change and the proliferation of muscle-nuclei which thus occur 
at an early period in scarlet fever in the renal vessels when the kidneys 
become affected are due to an irritating cause acting similarly to that in 
typhoid fever. 

Klein calls attention to the interesting examinations of the scarlatinous 
kidney made by Klebs, who attributed the diminished urination and the 
ursemic poisoning in certain cases in which the kidneys do not exhibit 
any marked change to the naked eye, to what he designates glomerulo- 
nephritis. Klebs says : " In the post-mortem examination the kidneys 
are found slightly or not at all enlarged, firm, . . . the parenchyma 
very hypersemic. Only the glomeruli appear, on close inspection, pale 
like small white dots. The urinary tubes are often not changed at all. 
Occasionally the convoluted tubes are slightly cloudy. The microscopic 
examination shows that there are neither interstitial changes nor pro- 
liferation of epithelium, the so-called renal catarrh generally supposed 
to be present in these conditions on account of the absence of other 
perceptible derangements ; and there seems, therefore, leaving out the 
glomeruli, the congestion of the kidneys alone to remain to account for 
the symptoms during life." But that mere congestion is insufficient to 
produce the symptoms appears from the fact that it does not cause 
them under other circumstances. Klebs finds, "on microscopic exam- 
ination of the glomerulus, the whole space of the capsule filled with 
small somewhat angular nuclei, embedded in a finely granular mass. 
The vessels of the glomerulus are almost completely covered by nuclear 
masses." 

Klein, commenting on these examinations by Klebs, states that in all 
early cases which he examined he observed great abundance of nuclei 
of the glomeruli, but a condition like that described and figured by 
Klebs 1 he has seen in only a few glomeruli ; for a general state of these 
bodies, as described by this observer, and such an excessive proliferation 
of the nuclei that the bloodvessels are completely compressed, was not 
seen in one of the twenty-three cases. Klein therefore questions 
whether the diminished urination and retention of urea in scarlet fever, 
when the kidneys do not exhibit any conspicuous catarrhal or other 

1 Handbuch der Pathol., p. 646, fig. 72. 



236 SCARLET FEVER. 

change, is due, unless in exceptional instances, to compression of the 
vessels of the glomeruli by nuclear germination, but believes, rather, 
that the obstructed circulation, and consequent diminished urinary 
excretion, is largely due to the changed state of the arterioles. Klein 
adds that perhaps undue contraction of the arterioles, through stimula- 
tion by the blood-irritant, may also be a factor in causing arrest of cir- 
culation in the Malpighian corpuscles. As regards cases that perished 
early, he found the parenchymatous change slight, so that a careful 
examination was required in order to detect cloudy swelling and gran- 
ular degeneration. 

2. Interstitial Nephritis. — A second set of changes Klein observed 
in cases that died about the ninth or tenth day. In such cases he 
found changes due to interstitial, in addition to those produced by paren- 
chymatous, nephritis. Round cells, lymphoid cells, or whatever else 
they should be called, were seen in the connective tissue of the kidneys. 
In the kidneys of those that died at the end of the first week after the 
commencement of nephritis, infiltration with round cells was observed 
in the connective tissue around the large vascular trunks. At a later 
stage this infiltration had extended into the bases of the pyramids and 
into the cortex. The gradual increase in extent and intensity of this 
infiltration was so decided in the cases which Klein observed, that he 
has no hesitation in concluding that when interstitial nephritis occurs it 
begins about the end of the first week, in the manner already stated — 
to wit, as a slight infiltration of the tissues around the large vascular 
trunks, and gradually extends, so that portions of the cortex, and rarely 
portions of the base of the pyramids, are changed into firm, pale, round- 
cell tissue, in which the original tubes of the cortex become lost. 

The infiltration of the cortex with round cells, beginning at the roots 
of the interlobular vessels, spreads rapidly toward the capsule of the 
kidney, and laterally among the convoluted tubes around the Malpighian 
bodies. ... In the course of this process considerable parts of the 
peripheral cortex, occasionally of a cuneiform shape, with the base 
nearest the capsule of the kidney, become changed into whitish, firm, 
bloodless, cellular masses, in which Malpighian corpuscles and urinary 
tubes are only imperfectly recognized, being more or less degenerated. 
In some cases attended by this infiltration of the cortex, Klein observed 
a more or less dense reticulation of fibres, especially around the inter- 
lobular arteries, containing in its meshes lymph-cells, chiefly uninuclear. 

In a child of five years that died after a sickness of thirteen days, 
Klein found evidence of intense interstitial inflammation, and also 
emboli, consisting of fibrin with a few cells, in the arteries, both in 
those of large size and in the arterioles, chiefly where they enter the 
Malpighian corpuscles. He states that in the specimens which he ex- 
amined the more intense the degree of interstitial change, the greater 
was the enlargement of the kidneys, and the more distinct also were the 
evidences of parenchymatous nephritis in the urinary tubes, which 
either contained casts or were in process of destruction. By being 
crowded with inflammatory products, especially cells, the Malpighian 
corpuscles were obliterated, undergoing fibrous degeneration. A very 
curious fact observed was the deposit of lime in the urinary tubes, first 



COMPLICATIONS AND SEQUELS. 237 

of the cortex, and then also of the pyramids, at an early stage of scarlet 
fever, when the kidneys otherwise showed only slight change. Several 
observers, as Biermer, Coats, and Wagner, have each described a case 
of scarlet fever with interstitial nephritis, which they consider unusual; 
but Klein has apparently demonstrated, as we have seen, by a large 
number of microscopic examinations, that this form of nephritis is 
common after the ninth or tenth day. 

Nephritis, in proportion to its extent and gravity, is accompanied by 
languor, febrile movement, thirst, loss of appetite and strength. At 
first the patient experiences but slight pain in the head or elsewhere 
and the quantity of urine is not notably diminished ; but as the disease 
continues urination becomes less frequent and the urine more scanty. 
Albuminuria occurs, while the urea is only partially excreted, and 
therefore it accumulates in the blood. If the nephritis be so severe or 
protracted that this principle accumulates to a certain extent, grave 
symptoms occur, as headache, vomiting, apathy or restlessness, and, 
more dangerous than all, eclampsia, which is not unusual in these 
cases. Microscopic examination of the urine shows the presence in 
this liquid of blood-corpuscles, granular epithelial cells, and hyaline or 
granular casts, or both. The specific gravity of the urine is diminished. 
But a large quantity of albumen in the urine may render the specific 
gravity as high or higher than in health. 

The altered state of the blood soon gives rise to transudation of 
serum, first observed in most cases as an anasarca occurring in the feet 
and ankles. The oedema, if not checked by treatment or through mild- 
ness of the disease, extends over the limbs, scrotum, and sometimes 
upon the trunk. It is well if the dropsy remain limited to the subcu- 
taneous connective tissue, but unfortunately, it is apt to occur, if the 
nephritis continue, in and around the internal organs, producing, men- 
tioned in the order of frequency, pulmonary oedema, effusion into the 
pleural and peritoneal cavities, the pericardium, the encephalon, and 
lastly into the connective tissue of the larynx, causing that very fatal 
complication, oedema of the glottis. Although this is the common 
order in which dropsies occur, exceptions are not infrequent. Even 
the anasarca may not be the first to appear, although in the vast 
majority of cases it has the precedence. Thus, Killiet relates the case 
of a boy of five years who twenty days after the occurrence of scarlet 
fever, and six hours after the appearance of bloody and albuminous 
urine, had double hydrothorax, rapidly developed. As long as the 
hydrothorax continued no anasarca was observed, but as it declined 
anasarca appeared. Legendre cites a case in which oedema of the 
lungs occurred without anasarca or other dropsy. Occasionally, the 
anasarca and internal dropsies take place nearly simultaneously. The 
nephritis and consequent serous effusions usually appear within three 
weeks after scarlet fever ends, but cases occur in which the effusions are 
first observed as late as the fourth and fifth weeks. The patient may 
be considered to possess immunity from this sequel if he have reached 
the close of the fifth week after the abatement of scarlet fever without 
its occurrence. 

The dropsy is usually acute, but it may assume the chronic form, 



238 SCARLET FEVER. 

since the nephritis which causes it, happily curable in most instances, 
may, if neglected, become chronic. Whether the dropsy in itself 
involve danger depends in great part on its location. Anasarca and 
ascites may exist a long time with little suffering or danger, but a small 
amount of serum in certain other localities causes alarming symptoms 
and speedy death. (Edema of the lungs, hydro-pericardium, oedema 
of the glottis, and intracranial effusions are always dangerous, and the 
last two are sometimes fatal within twenty-four to forty-eight hours. 
(Edema of the lungs has been fatal within twelve hours from the appear- 
ance of the first symptoms of obstructed respiration. 

Cerebral symptoms occurring during scarlatinous nephritis are prob- 
ably sometimes due to the irritating effect of the retained urea on the 
nervous centre. In other cases the cause appears to be cerebral oedema 
or compression of the brain by effusion of serum within the ventricles 
and upon the surface of the brain. Headache, dull or severe, dilata- 
tion of the pupils or their oscillation in a uniform light, vomiting with 
little apparent nausea, are common symptoms of scarlatinous nephritis 
when it has continued a few days, and the excretion of urea is so 
diminished that this substance begins to exert its poisonous effect on 
the system. Such symptoms are frequently followed by somnolence, 
threatening coma, or by eclampsia, unless the patients are promptly and 
properly treated. In some patients that die of scarlatinous nephritis, 
death occurring in convulsions or coma, no appreciable lesions are 
observed within the cranium, unless more or less congestion, the fatal 
ending being attributable to the uraemia. In other instances we find 
an effusion of serum within the ventricles or upon the surface of the 
brain. Although the symptoms in scarlatinous nephritis and uraemia 
may appear "very unfavorable, the prognosis is usually good under 
prompt and appropriate treatment. Thus severe convulsions and a 
decree of somnolence that bordered on coma mav abate, and convales- 
cence be fully established within a few days. Rilliet and Barthez 
announce ten recoveries in thirteen patients affected with convulsions 
due to this renal affection. 

Anatomical Characters. — Scarlet fever being, as we have seen, a 
constitutional febrile disease of an ataxic nature, and accompanied by 
certain inflammations, necessarily affects the composition of the blood ; 
but since this disease varies so greatly in type or severity, the state and 
appearance of this liquid also vary. At the autopsies of the more 
malignant cases we find the blood dark and fluid, with small, soft, and 
dark clots in the heart and large vessels. In other cases the clots are 
large, firm, and solid, as described in a preceding page. In malignant 
cases that end fatally Rilliet and Barthez state that both the large and 
small vessels of the cerebral meninges and the brain are found hyper- 
eemic, but in a variable degree. In those who die in coma, preceded by 
delirium or convulsions, during the eruptive stage, the intracranial con- 
gestion is usually marked, with perhaps some transudation of serum, but 
without inflammatory lesions. The fibrin in scarlet fever remains in 
about normal proportion, except as it is increased by inflammatory com- 
plications. Andral found an increase in the proportion of blood-cor- 
puscles from 127 to 136 parts in 1000. 



ANATOMICAL CHARACTERS. 239 

The respiratory apparatus, except the Schneiderian membrane, is 
usually normal when no complications exist. Samuel Fenwick 1 made 
post-mortem examinations in sixteen cases of scarlet fever, and concludes 
from them that inflammation of the mucous membrane of the stomach 
and intestines occurs like that of the skin, followed by desquamation of 
the epithelial cells, like that of the epidermis. I have had the oppor- 
tunity of examining the stomach and intestines of those who died of 
scarlet fever in the eruptive stage, and have not found any unusual 
hyperemia of the gastro-intestinal surface, except when gastro-intestinal 
inflammation, usually indicated by diarrhoea, had occurred as a com- 
plication. 

In some cases the abdominal organs exhibit changes which suggest a 
resemblance to typhoid fever. The spleen is enlarged and somewhat 
softened, and Peyer's patches and the solitary glands are thickened and 
prominent, but less in degree than in typhoid fever. The mesenteric 
glands also are in a state of hyperplasia. In other patients these parts 
appear normal. 

Klein made microscopic examination of the liver in eight cases, and 
states that he found granular opaque swelling of liver-cells, and changes 
in the internal and middle coats of certain arteries similar to those 
observed in the kidneys, which have been described above. He also 
found evidences of interstitial inflammation, as an increase of round 
cells and connective tissue in the liver. He remarks also that he 
observed hyaline degeneration of the intima of arteries in the spleen. 
Killiet and Barthez state that swelling and softening of the spleen are 
exceptional in scarlet fever, but are sufficiently common to merit atten- 
tion. In post-mortem examinations which I have witnessed nothing 
noteworthy has appeared to the naked eye in the state of the liver, nor 
ordinarily in that of the spleen. 

The efflorescence, though one of the anatomical characters, has per- 
haps been sufficiently described in the foregoing pages. It begins over 
the neck, chest, and groins as numerous reddish points not larger than 
a pin's head, closely crowded together, but with skin of normal color 
between. It is estimated that the aggregate efflorescence and aggregate 
normal skin over a given area are about equal. If the cutaneous circu- 
lation be active and the febrile movement be considerable these spots 
extend and coalesce, producing an efflorescence like erythema or like the 
hue of a boiled lobster, to which it has been likened. The efflorescence, 
less upon the face than upon the trunk, contrasts in this respect with 
that of measles, in which the rash is full in the face, often causing some 
swelling of the features. It is also less upon the palmar and plantar 
surfaces than elsewhere. It scarcely causes any perceptible elevation 
of the skin, but in certain localities, as upon the backs of the hands 
and upon the forearms, it communicates the sensation of slight rough- 
ness. The seat of the efflorescence is mainly in the superficial layers 
of the skin, but it is said that it sometimes has occurred upon a cicatrix, 
as that from a burn. In the robust and in favorable cases in which the 
circulation is active the rash has a scarlet hue, and when the cutaneous 
capillaries are emptied, and the skin rendered pale by pressure with the 

1 London Lancet, July 23, 1864. 



2-iO SCARLET FEVER. 

fingers, the circulation immediately returns when the pressure is removed. 
In malignant cases the color is not scarlet, but dusky red, and so slug- 
gish is the capillary circulation that the skin when pressed upon recovers 
the blood very slowly. In grave cases also extravasation of blood in 
minute points or transudation of its coloring matter is apt to occur in 
portions of the surface, when, of course, decolorization is not fully pro- 
duced by pressure. In cases ending fatally, during the eruptive stage 
the efflorescence may entirely disappear in the cadaver, or it remains 
upon parts of the surface, especially depending portions. Desquamation 
is attributable to the exaggerated proliferation of the epidermis and the 
loosening of its attachment by the inflammation. 

Diagnosis. — In the commencement of scarlet fever, prior to the 
eruption, no symptoms or appearances exist which enable us to make a 
positive diagnosis. Positive statement in reference to the nature of the 
attack should be deferred, for the credit of the physician. Still, if a 
child with no appreciable local disease sufficient to cause the symptoms 
a few clays after exposure to scarlet fever, or during an epidemic of this 
malady, be suddenly seized with fever, the pulse rising to 110, 120, or 
more, and the temperature to 102°, 103°, or 105°, scarlatina should be 
suspected. The diagnosis is rendered more certain at this early stage 
if vomiting occur, and especially if the fauces be red, for hyperemia of 
the fauces, due to commencing pharyngitis, is one of the earliest and 
most constant of the local manifestations of scarlatina. 

When the eruption has appeared, the nature of the malady is in most 
instances apparent. The punctate character of the eruption before it 
becomes confluent, its occurrence within twenty-four hours after the 
fever begins over almost the entire surface, but its absence or scantiness 
upon the face, and especially around the mouth, serve to distinguish it 
from other diseases. 

Scarlet fever and measles were long considered identical by the pro- 
fession, and, though the ordinary forms of these maladies can be readily 
distinguished from each other, cases occur in which the differential diag- 
nosis is attended by some difficulty. But there are differences in the 
symptoms and course of the two diseases which aid in discriminating 
one from the other. Measles begins with marked catarrhal symptoms, 
as if from a severe cold. Mild conjunctivitis, causing weak and watery 
eyes, coryza, and mild laryngo-bronchitis, with accompanying cough, 
precede the eruption three or four days and continue during the eruptive 
stage. The febrile movement in the prodromic stage of measles is 
remittent, the evening temperature being two or three degrees higher 
than that in the morning. Contrast this with the invasion of scarlet 
fever, in which the only catarrh is that of the buccal and faucial sur- 
faces, and there is consequently little or no cough, and the febrile 
movement, ordinarily high in the beginning, is nearly uniform in the 
different hours of the day. The scarlatinous eruption appears, as we 
have seen, within twelve to twenty-four hours about the neck and upper 
part of the chest, and spreads over the body in a shorter time than that 
of measles, which appears on the third day. The rash of measles 
begins to fade at the close of the third or in the fourth day after its 
appearance, that of scarlet fever not till from the sixth to the eighth 
day. In nearly all cases of measles, even when the rash is confluent 



, DIAGNOSIS. 241 

upon the face and a considerable part of the trunk, in consequence of 
the high febrile movement and vigorous cutaneous circulation, we observe 
the characteristic rubeolar eruption upon certain parts of the surface, 
as the extremities, which, in connection with the history, renders diag- 
nosis certain. 

Erythema resembles the scarlatinous eruption, but its duration is 
commonly shorter. It is limited to a part of the surface, and it is 
accompanied by much less febrile movement. The temperature in 
erythema does not usually rise above 100°, unless for a few hours, 
whereas in scarlet fever it continues considerably above 100° for several 
days. The scarlatinous efflorescence has also a brighter red or more 
scarlet hue than that of erythema, except in the more malignant cases, 
in which the severity of the symptoms renders the diagnosis clear. 
But an important aid in differentiating the one from the other of these 
diseases is the fact that in erythema there is, with few exceptions, no 
faucial inflammation, and in the few instances in which it is present it 
is slight and transient, fading within a day or two. 

Scarlet fever is readily diagnosticated from diphtheria, although the 
affinity is close between these two maladies. The early appearance of 
the pseudo-membrane upon the fauces in diphtheria, its absence in 
scarlet fever, and the absence of any appearance resembling it until 
the fever has continued some days, and the characteristic efflorescence 
upon the skin in scarlet fever, render diagnosis easy. If scarlet fever 
have continued some days when first seen by the physician, the diph- 
theritic pseudo-membrane may be present as a complication, or the 
fauces may present an appearance like diphtheria from ulceration or 
sloughing and the presence of foul and offensive secretions, which pro- 
duce a dark-grayish and fetid mass over the faucial surface. Under 
such circumstances the character of the disease is ascertained by the 
history of the case, and especially by the occurrence of the scarlatinous 
eruption. An erythema transient and limited to a part of the surface 
sometimes appears in the commencement of diphtheria, and at a later 
period, as a result of the toxaemia, upon the extremities. Roseoloid 
points and patches often occur upon the extremities. Both kinds of rash 
can be readily diagnosticated from that of scarlet fever, for the erythema, 
as has been stated, is transient and partial, and does not exhibit minute 
points of deeper injection, while the toxsemic rash differs in form and 
aspect from that of scarlet fever, and appears at a stage when the scarla- 
tinous efflorescence has faded or begun to fade. 

The efflorescence of rotheln sometimes closely resembles that of 
scarlet fever, though it is usually more like that of measles ; but it is 
ordinarily accompanied by symptoms which are much milder than those 
of scarlet fever, and it begins to abate as early as the third, and dis- 
appears on the fourth day. The eyes have a suffused appearance, the 
temperature may reach 102° or 103°, and the efflorescence may be as 
general over the body as that of scarlet fever, but there is not the aspect 
of serious indisposition, and the speedy abatement of the symptoms 
shows that the disease is not scarlet fever. 

Prognosis. — The prognosis depends on the form of scarlet fever, 
whether mild or severe, the strength of the patient, and the presence 

16 



24:2 SCARLET FEVE$. 

or absence of complications or sequelae. The type of the disease is 
sometimes so mild throughout an epidemic or during a series of years 
that death seldom occurs, whatever the mode of treatment ; but after- 
ward the type changes, and the percentage of deaths increases and 
remains high till another mitigation in the type occurs. 

Sydenham, in the middle of the seventeenth century, stated that 
scarlet fever, as he saw it in London, was so mild that it scarcely 
deserved the name of disease : " Vix nomen morbi merebatur." Morton 
some years later, and Huxham in the following century, had abundant 
reason to regret the change of type, and now throughout Great Britain 
scarlet fever is one of the most fatal and most dreaded of the diseases 
of childhood. In Dublin during the present century, prior to 1834, 
scarlet fever was uniformly mild, so that on one occasion of eighty 
patients in an institution all recovered. In 1834 the type of the disease 
totally changed and epidemics of unusual virulence occurred. The type 
frequently changes from mild to severe or severe to mild, not only in 
consecutive years, but in consecutive months. A few years since a dis- 
tinguished physician of New York treated about fifty cases of scarlet 
fever in one of the institutions without a single death, but a few months 
later the type of the malady changed, and his own son was among those 
who perished from it. The prevailing type of the disease should there- 
fore be considered in giving the prognosis when in the commencement 
of a case we are asked the probability as regards the termination. 

Extensive statistics, including those collected by Murchison from 
various sources, show that in different epidemics the mortality may 
vary as much as from 3 per cent. (Eulenberg, of Coblentz) to 19.3 per 
cent, (cases seen by myself in New York City in 1881-82, many of 
which were complicated by diphtheria), or even to 34 per cent, (epi- 
demic in the Palatinate in 1868-89). The hospital statistics of Rilliet 
and Barthez gave 46 deaths in 87 cases, or about 53 per cent. 

Observations have thus far failed to establish any connection in the 
atmospheric conditions of temperature or moisture and the type of 
scarlet fever. Grave as well as mild epidemics have occurred in all 
climates and seasons. 

The mortality is nearly equal in the two sexes, but age has a marked 
influence on the percentage of deaths. Comparatively few contract 
scarlet fever under the age of one year, and the period of its greatest 
mortality, and also of its greatest frequency, is between the ages of one 
and six years. The following are statistics bearing on the relation of 
the age to the percentage of deaths : 



Fleishman, Cases 
Deaths 



Kraus, Cases 

Deaths 



Voit, Cases 

Deaths 



From the close From the 5th to 

Under 1 year. of 1st till close the 12th 

of 5th year. year. 

8 204 260 

6 88 51 

1st to close of 6th to 12th From the 12th 

6th year. year. to 20th year. 

13 113 106 40 

4 29 10 2 

7th to 16th year. 

5 166 109 

1 24 10 



PROGNOSIS. 



243 



Reset, 



Cases 

Deaths 



Russig-er, Cases 
Deaths 



Under 1 year. 

. 43 

. 1G 



Under 5 years 
. 101 
. 21 



^Car?" Over 5 years. 

156 88 

31 3 



5 th to 10th year. 
12G 
20 



10th to 15th year. Over 15 years. 
47 27 

3 



These statistics, which I believe correspond with the observations of 
others, show that although few cases occur in the first year, the per- 
centage of deaths is large, and that a majority of the total deaths from 
this malady occur under the age of six years. After the sixth year the 
greater the age the less the proportionate number of deaths. 

Scarlet fever is liable to so many complications and sequelae that a 
physician should not predict a certain favorable termination in the 
beginning, however mild and regular the symptoms may be. But a 
favorable result may be expected if the attack be mild, the efflorescence 
appear at the proper time and extend over the entire surface, the angina 
be moderate and accompanied by little or no cellulitis or adenitis, with 
pulse under 140, temperature not above 103°, and no marked nervous 
symptoms. 

Whether the complications or sequelae be dangerous depends upon 
their character. Rheumatism has never in my practice been dangerous, 
nor has it materially retarded convalescence, except when it affected the 
heart, causing pericarditis or endocarditis, when it involves great danger. 
Nephritis, if it be moderate, attended by little albuminuria and serous 
effusion, and by the occurrence of few renal casts in the urine, commonly 
ends favorably under judicious treatment, as we have already stated ; 
but severe nephritis, with abundant albuminuria and casts and serous 
effusions, soon gives rise to alarming symptoms, and is the cause of death 
in a considerable number of instances. A similar remark is applicable 
to the angina, which occurs in all grades of severity. If it be attended 
by much cellulitis, with considerable ulceration or necrosis, the state is 
one of danger, in consequence of the difficulty in administering sufficient 
nutriment, as well as from the diminished assimilation and the loss of 
strength due to the prolonged inflammatory fever, the septic poisoning, 
and the occasional hemorrhages. Complication by pharyngeal or nasal 
diphtheria, now so common where diphtheria is endemic, also greatly 
increases the danger. 

Many cases, even wdien their course is normal and without complica- 
tions, involve danger, and some are necessarily fatal, from the direct 
effect of scarlatinous blood-poisoning. Such are grave or malignant 
forms of the disease which the experienced eye recognizes at a glance. 
Death often occurs rapidly from the toxaemia. Such cases are charac- 
terized by high temperature (105° or 106°), rapid pulse, dusky-red hue 
of the surface from languid capillary circulation, pungent heat, frequent 
vomiting, diarrhoeal stools, a dry-brown tongue, and marked nervous 
symptoms, such as delirium, great restlessness, or stupor. Not a few 
in this form of scarlet fever take eclampsia, which is apt to be severe 
and repeated, and to end in fatal coma. 

Other inflammatory complications and sequelae, which have been 



24:4: SCARLET FEVER. 

described in the preceding pages, retard convalescence and jeopardize 
the life of the patient, such as empyema, endocarditis, pericarditis, and 
pneumonia. Otitis media is seldom immediately dangerous, although it 
may be painful and involve serious consequences, even a fatal meningitis, 
as has been stated above, after months or years of otorrhoea. Anoma- 
lous cases are believed to be, as a rule, more dangerous than such as are 
attended by an early and full efflorescence and have the usual symptoms. 

Treatment. Prophylaxis. — Since the discovery by Jenner of the 
prophylactic power of vaccination as regards smallpox, the attention of 
the profession has been frequently directed to the prevention of scarlet 
fever. Belladonna has been employed for this purpose by a class of 
practitioners who believe in the theory that an agent which produces 
symptoms similar to those of a disease is antagonistic to that disease, 
and therefore tends to prevent it, or, if it be present, to render it 
milder; and since this herb causes an efflorescence upon the skin and 
redness of the fauces, it was selected as the proper preventive and 
remedial agent for scarlet fever. Its use, however, for this purpose has 
been fruitless, and it is now nearly or quite discarded. 

It is probable, from a considerable number of observations, that 
scarlet fever occasionally occurs in the domestic animals during epidemics 
of the disease in children. It is stated that Spinola observed it in the 
horse; that Heim saw a dog that occupied the same bed with a scarla- 
tinous patient sicken with fever, which was followed by desquamation ; 
that Letheby saw scarlatina in swine, and Kraus in young cattle. 
Prominent veterinary surgeons, as Williams, of Great Britain, admit the 
occurrence of scarlatina in animals, and the hope has arisen that since 
smallpox is modified in cattle so as to aiFord us the vaccine virus, per- 
haps scarlet fever may also be modified by passing through one of the 
lower animals, so that a milder and less fatal form of the disease might 
be produced in man by inoculation from the animal. This theory, 
though it deserves investigation, is far from being established. It has 
not yet, so far as I am aware, been shown that scarlet fever is milder in 
any animal than in man, nor, if we admit that it is modified in the 
animal, is it certain that the disease could be returned to man in the 
modified form. In the JST. Y. Medical Record for March 24, 1883, 
some experiments are detailed by S. W. Strickler of Orange, New 
Jersey. He cites the experiments of Caze and Feltz, who injected 
scarlatinal blood under the skin of sixty-six rabbits, and of these sixty- 
two died within eighteen hours to fourteen days, which indicated a 
highly poisonous state of the blood employed, either septic or scarla- 
tinous, and certainly no mitigation of the virulence of the scarlet fever. 
Strickler obtained from Williams, of Edinburgh, nasal mucus from a 
horse supposed to have scarlatina, and with it inoculated twelve children, 
all of whom had sores at the point of inoculation, with redness of the 
skin around the sores, and in some instances swelling of the adjacent 
lymphatic glands. It is stated that the children thus inoculated did 
not contract scarlet fever subsequently when they were exposed to 
it. Obviously, there is a serious objection to such experiments upon 
children, so that they may not be repeated, but a movement has been 
made in one of the New York medical societies looking to the appoint- 



TREATMENT — PROPHYLAXIS. 245 

ment of a competent committee to investigate them. Some of the promi- 
nent veterinary surgeons of this city do not attach much importance to 
the experiments thus far made, since they are in doubt whether the virus 
employed was that of the genuine disease. 

It is a matter of great interest and importance, and one not yet eluci- 
dated, whether or to what extent disinfectant and antiseptic remedies 
administered internally, prevent the occurrence of the infectious maladies 
in those who have been exposed, and aid in curing those who are sick 
with them. Sodium sulpho-carbolate, from which, by decomposition in 
the system, carbolic acid is supposed to be set free, has been used for 
this purpose. It is administered to adults in doses of ten to thirty 
grains, and to children in doses proportionate to their age. Declat has 
prepared a syrup of phenic (carbolic) acid as a preventive and curative 
agent in the infectious diseases. It is now employed by several of the 
New York physicians, but thus far the statistics of its use are not suffi- 
cient to determine its efficacy. It is a question whether the so-called 
antiseptics can, on account of their toxic properties, be used with safety 
in doses sufficiently large to be antidotal to the specific principle of any 
of the infectious maladies. 

It is not my intention to recommend in this treatise any remedial 
agent that has not been fully tried and its efficacy determined ; but 
from observations made by myself in nearly twenty families in which 
scarlet fever was prevailing, I am convinced that boracic acid (acidum 
boricum), an antiseptic recently introduced into our Pharmacopoeia, 
deserves trial as a preventive and antidote of scarlet fever as well as 
diphtheria. The good result in my practice from the use of this agent, 
which only extends over about six months, may be due to the present 
type of scarlet fever, but I have been surprised at the favorable progress 
of the cases which appeared very grave in the beginning, at the small 
mortality, and at the large proportion of well children exposed to scar- 
latinous cases that escaped infection, to whom this medicine was regu- 
larly administered. Boric (boracic) acid has been recently used by 
aurists with remarkable success in suppurating and granulating otitis 
media, and by oculists as an eye-wash. E. R.. Squibb says of it 
{Ephemeris, May, 1883): "A solution saturated at ordinary tempera- 
tures contains between 4 and 5 per cent It is a very bland and 

soothing application, whether applied in powder or solution, relieving 

irritation and reducing suppuration It has been administered 

internally in large doses without any disturbing effect. The prepara- 
tion which I have employed is one found in the shops, with the name 
listerine, prepared by a Western pharmaceutical firm. It contains, 
according to the manufacturers, the "essential antiseptic constituents 
of thyme, eucalyptus, baptisia, gaultheria, and mentha arvensis," and 
also two grains of benzo-boracic acid in each drachm. The dose of 
listerine which I have employed for an adult is one teaspoonful, con- 
siderably diluted with cold water. A child of five years can take ten 
to fifteen drops every two to four hours. I call the attention of the 
profession to the use of boracic acid as an antidote to the scarlatinous 
poison, without sufficient experience to enable me to speak positively 
of its efficacy, but with the hope and expectation, from observing its 



246 SCARLET FEVER. 

apparent effects in seventeen families afflicted with scarlet fever, that it 
will be found a useful addition to our means of controlling this much- 
dreaded and fatal malady. 

In the present state of our knowledge the most reliable and certain 
prophylaxis is the isolation of patient and nurses, and the thorough and 
judicious employment of disinfectants upon their persons and in the 
apartments. All furniture and articles not absolutely required should 
be removed from the sick-room, and no one should be allowed to enter 
it except the medical attendant and nurses. Constant ventilation should 
be insisted on by lowering the upper and raising the lower sash of the 
window two or three inches in mild weather. Even in stormy weather 
sufficient ventilation can be obtained in this way without exposing the 
patient to currents of air, which should be avoided. 

Since the exhalations from the body, the various excretions, and the 
epidermic cells shed so abundantly in the desquamative period contain 
the scarlatinous poison, measures should be employed to disinfect them, 
in so far as the comfort and well-being of the patient will allow. Vessels 
which receive the excretions should contain carbolic acid, chloride of 
lime, or other disinfectant, and they should be immediately emptied and 
cleaned after use. By the frequent application of disinfecting washes 
to the nostrils and fauces the secretions from these surfaces are to a 
great extent deprived of their contagiousness. If otorrhcea occur, 
boracic acid, so serviceable in its treatment, acts as a disinfectant, but 
in addition the ear should be syringed with warm carbolized water, one 
drachm of carbolic acid to the pint of water, and this should be con- 
tinued during convalescence, for cases occur which show that the dis- 
charge from the ear is probably the vehicle by which the virus is 
communicated. Even as late as the fourth week after the disappear- 
ance of the rash children in scarlet fever experience relief from inunc- 
tion of the surface, and if carbolic acid be added to the substance which 
is employed for this purpose, and the inunction be made twice daily over 
the entire surface, contamination of the air through the exfoliations and 
exhalations from the skin is in great part prevented. The late William 
Budd, of Bristol, England, was in the habit of recommending inunction 
of the surface twice daily with sweet oil, which answered the purpose 
of preventing dissemination of epidermic particles through the air : and 
we will presently see how successful were his precautionary measures. 

A convalescent child should not be allowed to mingle with other chil- 
dren till three or four weeks have elapsed and desquamation has ceased; 
and all who are liable to take the malady should be excluded from the 
room in which a case has occurred for a longer period, and until it has 
been thoroughly disinfected by burning sulphur or other methods. 

The New York Board of Health enforces the following excellent regu- 
lations to prevent the spread of scarlet fever as well as other acute in- 
fectious maladies : 

" Care of Patients. — The patient should be placed in a separate room, 
and no person except the physician, nurse, or mother allowed to enter 
the room or to touch the bedding or clothing used in the sick-room until 
they have been thoroughly disinfected. , 



HYGIENIC TREATMENT. 247 

" Infected Articles. — All clothing, bedding, or other articles not abso- 
lutely necessary for the use of the patient should be removed from the 
sick-room. Articles used about the patients, such as sheets, pillow- 
cases, blankets, or clothes, must not be removed from the sick-room 
until they have been disinfected by placing them in a tub with the fol- 
lowing disinfecting fluid ; eight ounces of sulphate of zinc, one ounce 
of carbolic acid, three gallons of water. They should be soaked in this 
fluid for at least an hour, and then placed in boiling water for washing. 

" A piece of muslin one foot square should be dipped in the same 
solution and suspended in the sick-room constantly, and the same 
should be done in the hallway adjoining the sick-room. 

"All vessels used for receiving the discharges of patients should have 
some of the same disinfecting fluid constantly therein, and immediately 
after being used by the patient, should be emptied and cleansed witk 
boiling water. Water-closets and privies should also be disinfected 
daily with the same fluid or a solution of chloride of iron, one pound 
to a gallon of water, adding one or two ounces of carbolic acid. 

" All straw beds should be burned. 

" It is advised not to use handkerchiefs about the patient, but rather 
soft rags, for cleansing the nostrils and mouth, which should be imme- 
diately thereafter burned. 

"The ceilings and side-walls of a sick-room after removal of the 
patient should be thoroughly cleaned and lime-washed, and the wood- 
work and floor thoroughly scrubbed with soap and water." 

By such measures of prevention there can be no doubt that the 
number of cases of scarlet fever would be greatly reduced. 

Budd for years recommended similar precautions in the families which 
he attended, and the following is his testimony in regard to the result : 
"The success of this method in my own hands has been very remark- 
able. For a period of nearly twenty years, during which I have em- 
ployed it in a very wide field, I have never known the disease to spread 
beyond the sick-room in a single instance, and in very few instances 
within it. Time after time I have treated this fever in houses crowded 
from attic to basement with children and others, who have nevertheless 
escaped infection. The two elements in the method are separation on 
the one hand, and disinfection on the other." 1 

Hygienic Treatment. — The room occupied by a scarlatinous patient 
should be commodious and sufficiently ventilated. Its temperature 
should be uniform at about 70° during the course of the fever. When 
the fever begins to abate and desquamation commences, a temperature 
of 72° to 75° is preferable, so that there is less danger that the surface 
may be chilled during unguarded moments, as at night, when the body 
may be accidentally uncovered, since sudden cooling of the surface at 
this time may cause nephritis or some other dangerous inflammation. 
Henoch does not believe in the theory that the nephritis is commonly 
produced by catching cold, but many observations show that those who 
are carefully protected from vicissitudes of temperature, who remain 
during convalescence in a warm room, and are protected by abundant 

1 British Medical Journal, January 9, 1869. 



248 SCARLET FEVER. 

clothing, more frequently escape this complication than such as are 
under no restraint of this kind and are carelessly exposed in times of 
changeable weather. Nevertheless, it is true that a certain proportion 
suffer from nephritis however judicious the after-treatment may be. 
The best hygienic management does not always prevent its occurrence. 
The patient should not, therefore, leave the house until four weeks after 
the beginning of the fever, and in inclement weather not till a longer 
time has elapsed. So long as desquamation is going on and the skin 
has not regained its normal function, the patient should remain indoor, 
and when finally he is allowed to leave the house he should be warmly 
clothed. 

Therapeutic Treatment. — In order to treat scarlet fever success- 
fully, it is necessary to bear in mind that it is a self-limited disease, 
running for a certain time and through certain stages, and that it is not 
abbreviated by any known treatment. Therapeutic measures can only 
moderate its symptoms and render it milder. The severity of the dis- 
ease is indicated by its symptoms, and the symptoms are to a certain 
extent under our control. 

Mild Cases. — A patient with a temperature under 103°, and with 
only a moderate angina, does not require active treatment, but, however 
light the disease, he should always be in bed and in a room of uniform 
temperature, as stated above. Instances have come to my notice in the 
poor families of New York in which scarlet fever was not diagnosticated, 
and the patients were allowed to go about the house, and even in the 
open air, in the eruptive stage, till some severe complication or an 
aggravation of the type created alarm and medical advice was sought, 
when it appeared that a grave and dangerous condition had, through 
carelessness and ignorance, resulted from a mild and favorable form of 
the malady. The physician, when summoned to a case however mild, 
should never fail to take the temperature, note the pulse, inspect the 
fauces, and inquire in reference to the fecal and urinary evacuations, 
that he may detect early any unfavorable changes which may occur. 

Since in all cases angina and more or less blood-deterioration are 
present, the following prescription will be found useful in mild as well 
as severe scarlet fever: 

R. — Potass, chlorat gij. 

Tr. ferri chloridi . . . . . . fgij. 

Syrupi fjiv- — Misce. 

Sig. — Half a tea«poonfnl every hour to two hours to a child of three years ; a 
teaspoonful to a child of six years. 

Small doses of this medicine frequently administered act beneficially 
on the surface of the throat and tend to prevent the angemia which is 
so common after scarlet fever. If the medicine be given gradually 
diluted with only a moderate amount of water, the effect is better on 
the inflamed fauces. Potassium chlorate is known to be an irritant to 
the kidneys in large doses, causing intense hyperemia of these organs, 
with bloody urine or suppression of urine. The melancholy fate of 
Fountaine, who died from the effects of one ounce of this medicine, is 
known to the profession. I have seen a similar instance in a child. 



ORDINARY CASES AND CASES OF SEVERE TYPE. 249 

But doses of one to four grains, according to the age, can be admin- 
istered with safety to children, so that half a drachm to a .drachm and 
a half are taken in twenty-four hours. A quantity much exceeding 
this amount involves risk. In mild cases it is not necessary to treat the 
throat by topical measures, the above prescription producing sufficient 
local eifect, but camphorated oil may be used externally. I ordinarily 
prescribe quinine in small doses for this form of scarlatina, as in the 
following formula: 

R. — Quinise sulphat gr. xvj. 

Ext. glycyrrhizse . . . . B ss - 

Syr. pruni virginianae ..... fjij- — Misce. 

Sig. — One teaspoonful every fourth hour to a child of three to five years, the 
potassium chlorate and iron mixture being administered twice between. 

The treatment of scarlatina by antiseptic remedies will be considered 
hereafter. 

The itching and dryness of the surface, which increase the discomfort 
of the patient in mild as well as severe scarlatina, are relieved by fre- 
quently anointing the whole body with vaseline, cold cream, or butter 
of cocoa. Carbolic acid is an efficient remedy for pruritus, while it is 
also a disinfectant. It may be used in the following formula : 

$. — Acidi carbolici. ....... zj. 

Vaseline 31 v. — Misce. 

Sig. — To be applied over the entire surface. 

In New York leaf lard has long been employed as an unguent over 
the entire surface in scarlet fever, and patients experience benefit from 
it. Alcohol and water or vinegar and water are sometimes employed 
for the same purpose. The linen should be changed every day and the 
bed thoroughly aired. 

Ordinary Cases and Cases of Severe Type. — A safe tempera- 
ture in scarlet fever may be considered at or below 103°. If it rise 
above this, measures designed to abstract heat are very important — more 
important even in many cases than the medicinal agents which are com- 
monly used to combat this disease. Since a high temperature retards 
assimilation, promotes deleterious tissue change, and causes rapid emacia- 
tion and loss of strength, measures designed to reduce it are urgently 
needed. "The production of heat depends chiefly on oxidation of the 
constitutents of the body" (Billroth). Therefore fever indicates an 
increase of the oxidation and a molecular disintegration above the 
healthy standard. Hence, the augmentation of urea in the urine and 
the progressive emaciation and loss of weight which characterize the 
febrile state. Fever also diminishes the secretions by which food is 
digested and destroys the appetite, so that repair of the waste is in- 
sufficient. Moreover, a high temperature continuing for a time tends 
to produce degenerative changes, albuminous and fatty, in the tissues, 
the more rapidly the higher the temperature, so that the functions of 
organs are seriously impaired. Among the most dangerous of the 
tissue-changes is granulo-fatty degeneration of the muscular fibres of 
the heart. In dogs and rabbits that have perished from a high tempera- 



250 SCARLET FEVER. 

ture artificially produced by experimenters granular clouding of the 
elementary tissues has been found after death. 1 A high temperature, 
therefore, in itself involves danger, and if it occur in an ataxic disease 
like scarlet fever, and be protracted, it greatly diminishes the chances 
of a favorable issue. 

The temperature can be reduced without shock or injury to the child 
by the judicious use of cold water externally. The cold water treat- 
ment is not necessary if the temperature be under 103°, though useful 
if judiciously employed by sponging when the temperature is at 102° 
or 103° ; but if it rise above 103° it is required, and the more urgently 
the higher the temperature. The external use of cold water as an 
antipyretic in the febrile diseases is now most universally recommended 
by physicians, but it still meets with opposition on the part of families, 
especially in the treatment of the exanthematic fevers, and the direc- 
tions for its employment are therefore not apt to be fully carried out 
during the absence of the medical attendant. The old theory that the 
fevers require warmth and sweating has such a firm hold on the popular 
mind that some years longer will be required for its removal. 

The modes of applying cold water recommended by cautious and 
experienced physicians are various. Yon Ziemssen recommended that 
the patient be immersed in water at a temperature of 90°, and cool 
water be gradually added till the temperature fall to 77°. In a few 
minutes the patient is returned to his bed, his surface dried, and he is 
covered by the proper bedclothes, when his temperature will probably 
be found reduced two or two and a half degrees. If the patient com- 
plain of chilliness or his pulse be feeble, he should be immediately 
removed from the bath and stimulants administered, either whiskey or 
brandy, for if the extremities remain cool and the capillary circulation 
sluggish, the effect may be injurious, since some internal inflammation 
may arise to complicate the fever. Under such circumstances increased 
alcoholic stimulation is required. 

The cold pack is also effectual for reducing the temperature. The 
patient is placed upon a mattrass protected by oil cloth, and is covered 
by a sheet wrung out of water at a temperature of 70°. This is covered 
by one or two blankets. In half an hour he is returned to bed, and will 
be found to have a temperature two or three degrees less than that before 
the bath. Another method is to apply the sheet wrung out of water at 
90°, and then reduce the temperature by adding water at a lower degree 
from a sprinkler. In most cases, however, I prefer to reduce the tem- 
perature by the constant application to the head of an India-rubber bag 
containing ice. The ba^s should be about one-third filled, so that it 
should fit over the head like a cap. At the same time, as a potent means 
of abstracting heat, at least when the temperature is at or above 104°, a 
similar application should be made by an elongated rubber bag lying over 
the neck and extending from ear to ear. Cold applied over the great 
vessels of the neck promptly abstracts heat from the blood, while it 
diminishes the pharyngitis, adenitis, and cellulitis ; which is an impor- 

1 See experiments by Mr. J. W. Legg, Lond. Path. Soc. Trans., vol. xxiv., 
and others. 



ORDINARY CASES AND CASES OF SEVERE TYPE. 251 

tant gain. At the same time, it is proper to sponge frequently the hands 
and arms with cool water. If the temperature with this treatment be 
not sufficiently reduced, one or two thicknesses of muslin frequently 
wrung out of ice-water should be placed along the arms and upon either 
side of the face. By such local measures, which are agreeable to the 
patient and without any shock or perturbing effect on the system, we 
can reduce the temperature two or three degrees. By adding alcohol or 
one of the alcoholic compounds to the water the popular objection to the 
use of cold is overcome. 

Trousseau, in the treatment of sthenic cases attended by a high tem- 
perature, was in the habit of placing the patient naked in a bath-tub, and 
directing three or four pailfuls of water to be thrown over him in a 
space of time varying from one quarter of a minute to one minute, after 
which he was returned to bed and covered by the bedclothes without 
being dried. Reaction immediately occurred, often with more or less 
perspiration. This treatment was repeated once or twice daily, according 
to the gravity of the symptoms. Trousseau, alluding to this treatment, 
says: "I have never administered it without deriving some benefit." 
But the application of cold water in a manner that does not excite or 
frighten the patient seems preferable. Henoch, having a large experi- 
ence, gives the following advice in reference to the w T ater treatment : 
" If the fever continue high and the apparently malignant symptoms 
described above develop, the head should be covered with an ice-bag, 
. . . . and the child placed in a lukewarm bath, not under 25° R. 
(88.25°F.). I decidedly oppose cooler baths, because in scarlatina, which 
presents a tendency to heart-failure, cold may produce an unexpected 
rapid collapse more than in any other affection. But I strongly recom- 
mend washing the entire body every three hours with a sponge dipped 
in cool water and vinegar." 1 In grave cases with a high temperature the 
application of cold should be sufficient to produce a decided reduction of 
heat, otherwise the full benefit from its use is not obtained. With proper 
stimulation and proper precautions prostration does not occur from the 
ice-bags to the head and neck and cool sponging of other parts, so long 
as the temperature does not fall below 102° or 103°. The danger 
alluded to by Henoch can only occur from the use of the pack or general 
bath, and the water treatment can be efficiently carried out and the tem- 
perature sufficiently reduced without resorting to these. Even Currie, 
of Edinburgh, who first drew attention to the benefit from the cold water 
treatment of scarlet fever in an age when the sweating treatment, and 
even the exclusion of cool and fresh air from the apartment, were deemed 
necessary, recommended cold effusion only in sthenic cases with full and 
strong pulse, and he mentions as a warning two cases with quick and 
feeble pulse and cool extremities in which death occurred immediately 
after the use of the water. 

Sodium salicylate is in some instances a useful remedy for the reduce- 
tion of heat in the infectious diseases. It seems to be more decidedly 
antipyretic than quinine in the febrile and inflammatory diseases, though 
somewhat depressing to the heart's action. James Couldrey writes to 

1 Diseases of Children. 



252 SCARLET FEVER. 

the London Lancet (Dec. 1882, p. 10G4) that he has derived great 
benefit from its use in seven cases of scarlet fever. He administered it 
every two hours till ringing in the ears was produced, and afterward 
every four hours, prescribing one grain for each year in the age of the 
patient. It is, in my opinion, a proper remedy when the pulse is full 
and strong and the temperature is not sufficiently reduced by the cold 
water treatment. 

Aconite and veratrum viride reduce fever, but they are too depressing 
to be safely employed in grave scarlet fever, and their antipyretic effect 
is less than that of water. The use of digitalis might be suggested by 
the quick and feeble pulse in certain cases that are attended by high 
temperature, but the judgment of the profession is for the most part against 
its use in such cases. What Stille and Maisch state of its employment 
in typhoid fever appears equally applicable to scarlet fever: "Even its 
advocates have not shown that it abridges the disease or lessens its 
mortality, while it is abundantly demonstrated to impair the digestion, 
reduce the strength, and even to occasion sudden death. The use of 
digitalis in other forms of fever is equally unsatisfactory, and justifies 
the judgment of Traube, that the true field of action for digitalis is not 
fever." 

Quinine is the medicine which above all others has been . heretofore 
most used, by almost common consent of the profession, to reduce the 
temperature in malignant scarlet fever, but its use for this purpose is, 
according to my observations, far from satisfactory. To obtain its anti- 
pyretic action it must be administered in large doses, and if any of the 
quinine salts in ordinary use be administered by the mouth in sufficient 
quantity, they are apt to be vomited. To a child of five years five grains 
should be administered twice daily by the mouth, or ten grains of a 
soluble salt, as the bisulphate, may be given per rectum, dissolved in a 
little warm w T ater. Administered per rectum, it is frequently not re- 
tained unless held for a time by a napkin. A considerable proportion 
of the malignant cases are attended by not only irritability of the 
stomach, already alluded to, but by diarrhoea, so that quinine, if admin- 
istered at all, should be employed hypodermically. The double salt of 
quinia and urea answers for this purpose, as it is very soluble in water 
and does not produce inflammation of the connective tissue. When the 
antipyretic doses of quinine are discontinued, this agent may be pre- 
scribed as a tonic in the doses recommended for the treatment of mild 
scarlet fever. 

In severe cases with frequent and rapid pulse in which ante-mortem 
heart-clots are apt to occur, the ammonium carbonate is often useful. It 
should be dissolved in water and given in milk, in as large doses as five 
grains every hour or second hour to a child of five years. It aids in 
producing stronger contraction of the cardiac muscular fibres, and thus 
diminishes the danger of the formation of thrombi. Ten-drop doses of 
the aromatic spirits of ammonia may be employed instead of the carbo- 
nate, given in sweetened water. It is especially useful if the stomach 
be irritable. 

In severe cases attended by considerable angina and foul and offensive 
secretions upon the faucial surface an antiseptic, as boracic acid in small 



ANTISEPTIC TEE ATM EXT. 253 

quantity, should be added to the potash and iron mixture recommended 
above. If no drink be allowed for a few minutes after the dose, so as 
not to wash it too soon from the fauces, the antiseptic effect is more cer- 
tainly produced. Those old enough should be directed to hold the medi- 
cine for a moment like a gargle in the throat before swallowing it. I 
employ boracic acid by preference, as in the following formula : 

]£. — Acid, boracic. £ss. 

Potass, chlorat. gij. 

Tr. ferri chloridi . . . ■ . . . f ^ ij . 

G-lvcerinse, f._ --. 

byrupi ........ l. OJ 

Aquse f^'j- — ^lisce. 

Sig. — Give one teaspoonful every two hours to a child of five years. 

More minute directions will presently be given for the treatment of 
the pharyngitis when w r e speak of the complications. 

Alcohol, wiiether administered in one of the stronger whines, as sherry, 
or in whiskey or brandy, is a most useful remedy in scarlet fever, and is 
indeed indispensable in all grave cases which are attended by feeble capil- 
lary circulation and evidences of prostration. Milk is also the best 
vehicle for this agent. The wine-whey or milk-punch should be given 
every hour or second hour. In scarlet fever, as well as diphtheria, com- 
paratively large doses are required, as a teaspoonful of the stimulant 
every hour or second hour for a child of five years. 

During convalescence the hygienic treatment already described is 
important. Nutritious diet and a moderate amount of alcoholic stimu- 
lants are required, while the patient is kept indoor and protected from 
currents of air as long as desquamation is occurring. More or less 
anaemia is present in most convalescent patients, so that a mild tonic 
containing iron will aid in restoring; the health. Elixir of calisava-bark 
and iron; preparations of beef, iron, and wine, or the following pre- 
scription,' will be found useful under such circumstances: 

R. — Ferri et ammon. citrat. 

Amnion, carbonat. ...... aa J^ss-^j. 

Syrupi f|j. 

Aquas folj- — Misce. 

Sis:. — Dose, one or two teaspoonfuls, according to the age, in water, every second 
or third hour. 

Antiseptic Treatment. — It is still to be determined whether or to 
wdiat extent antiseptics, administered internally, antagonize and control 
the scarlatinous poison, and are, therefore, curative of scarlet fever. 
The most important agent of this class, carbolic acid, can only be em- 
ployed in small doses, for a dose much exceeding a drop for a child, or 
even exceeding a fractional part of a drop for a young child, might pro- 
duce poisonous symptoms. Carbolic acid is a cardiac and arterial seda- 
tive, and it appears to reduce temperature. Intrauterine injections of 
carbolized w^ater in the treatment of puerperal fever are known to reduce 
temperature, even when there is no septic matter in the uterus to be 
disinfected and washed away, as in a case related to me in which the 



254 SCARLET FEVER. 

fever proved to be due to measles. It is not improbable that the anti- 
pyretic action in patients of this class who have no septic substance 
within the uterus is due largely, if not mainly, to the absorption of 
carbolic acid from the uterine surface and its sedative action on the 
vascular system. Whether this agent, so highly extolled by Declat, 
and to which I have alluded in a preceding page, can be safely employed 
in doses large enough to be efficient and curative will be determined by 
future observations. The same remark is applicable to the sulphoear- 
bolate of sodium, whose antiseptic action is supposed to be due, as 
already stated, to the liberation of carbolic acid in the system. Since 
boracic acid does not seem to have any deleterious action, this agent has 
been administered to most of my scarlatinous patients during the last 
year, in addition to the older and better known remedies, and with a 
very small percentage of deaths. What may be the result in a more 
severe type of the disease remains to be seen. 

Treatment of Complications and Sequelae. — Local measures 
designed to diminish or cure the pharyngitis are important in all but 
the mildest cases. They are more especially required in the anginose 
variety and in those not infrequent cases in which diphtheria complicates 
scarlatina. Formerly it was necessary, in making applications to the 
fauces, to employ the brush or probang for those too young to use the 
gargle, but hand-atomizers, as Richardson's or Delano's, which are now 
in common use, afford a quick and easy method for making such appli- 
cations. Six or eight compressions of the bulb of a good atomizer are 
sufficient to cover the fauces with the spray. Those hand- atomizers in 
the shops which have slender metallic points are apt to prick the buccal 
surface and cause bleeding if the child resist and toss the head. To 
prevent this, I am in the habit of directing India-rubber tubing to be 
drawn over the point in such a way as* not to obstruct its action. The 
following will be found useful mixtures for the atomizer : For ordinary 
cases, 

R. — Acidi carbolici gss, vel. Acid, boracic. ^ij. 

Potass, chlorat. zij. 

Glycerinae f ^ ij . 

Aquas f 3 vj . — Misce. 

If the surface of the throat be covered by foul secretions, 

R. — Acidi carbolici .... 
Potass, chlorat. .... 
Glycerinas ..... 
Aquae calcis .... 




Or else, 



R • — Tine, ferri cbloridi 
Acidi sulphurosi 
Potass, chlorat. . 
Glycerinse. 
Aquae 




-Mis 



If diphtheritic exudation complicate the scarlatinous angina, or the sur- 
face of the throat in consequence of ulceration or necrosis present an 



TREATMENT OF COMPLICATION'S AND SEQUELS. 255 

appearance like that in diphtheria when the exudation begins to soften, 
bein<? foul, jagged, of a dirty brown appearance from dead matter and 
fetid secretions, those mixtures for spraying the throat will be found 
useful which are recommended in our remarks relating to the local 
treatment of diphtheria. 

The following mixtures are also beneficial for local treatment when the 
feudal surface is foul and offensive from the exudations and secretions. 
They should be applied by a large camel's-hair pencil every three to six 

hours : • 

R . — Acidi carbolici gtt. x. 



Liq. ferri subsulphatis 
Glycerinse 

J£ ._01. citronelli . 
Iodoform . 
Vaseline . 



fgj. — Misce. 
gtt. vj. 

pi- 



In all cases of scarlatinous pharyngitis sufficiently severe to require 
special treatment, cool applications should be made over the neck from 
ear to ear, as by two thicknesses of muslin frequently squeezed out of 
cold water, or by the elongated India-rubber bag already recommended 
in our remarks relating to methods to reduce temperature. 

In the first days of scarlet fever the coryza is slight, and no dis- 
charge from the nostrils occurs, so that no local treatment is required ; 
but before the termination of the malady, in cases of ordinary gravity, a 
nasal discharge usually supervenes, producing more or less redness and 
excoriating the upper lip. Moreover, in localities where diphtheria 
occurs, if this malady complicate scarlet fever, it is apt to affect the 
nostrils at the same time that the fauces are invaded. These conditions 
require local treatment of the nares. It should be remembered that 
the Schneiderian membrane is midway in sensitiveness, as it is in loca- 
tion, between the conjunctival and buccal surfaces, and is readily irri- 
tated by strong applications. Medicinal applications made to it must 
be much milder than those which the fauces tolerate. They should 
always be applied warm, and a teaspoonful of any mixture properly 
employed is sufficient for each nostril at one sitting. The applications 
should usually be made every two or four hours, according to the 
gravity of the case and the amount of discharge. The best instrument 
for this purpose is a small syringe of glass or brass with curved neck 
and bulbous tip. The child's head should be thrown back and the 
piston depressed rapidly, so as thoroughly to wash out the nasal cavity. 
The application can also be made through an atomizer with a rounded 
tip or a tip covered by rubber tubing. The following is a useful pre- 
scription : 

R. — Acidi carbolici gss. 

Sodii chloridi . . . . . . . gij. 

Aquae . Oj. 

The substitution of 2 or 3 drachms of boracic acid in place of the 
carbolic acid makes a nicer preparation. If the diphtheritic pseudo- 
membrane appear in the nares, the officinal lime-water, injected every 
hour or second hour, is beneficial in consequence of its solvent action on 
pseudo-membranes. 



256 SCARLET FEVER. 

It is evident, from what lias been stated above, that the condition of 
the ear should be closely observed in and after scarlet fever. If the 
patient have earache, considerable relief may be obtained in the com- 
mencement by dropping a few drops of laudanum and sweet oil into 
the ear and covering it by some hot application, either dry or moist, 
which will retain the heat. A light bag containing common table-salt, 
heated, or dry and hot chamomile flowers, will also answer the purpose. 
Water as hot as can be well tolerated dropped into the ear or allowed 
to trickle from a fountain syringe, so as to fill the ear, is also very bene- 
ficial in allaying the pain. If a few drops of laudanum be added, it is 
more useful. If the pain be not quickly relieved, a leech should be 
applied at the base of the tragus. 0. D. Pomeroy, an experienced 
aurist of New York, says: "Leeching employed at the right time 
rarely fails to subdue the pain and inflammation. The posterior face 
of the tragus is ordinarily the best place for applying the leech, but it 
may be applied in front of the ear or behind, wherever the tenderness 
on pressure is greatest. In my opinion, paracentesis may frequently be 
rendered unnecessary by the timely use of one or two leeches applied to 
the meatus." 

If the otitis continue, as shown by pain in the ear, of which chil- 
dren old enough to speak bitterly complain, and which causes those too 
young to speak to press their fingers into or against their ears, this in- 
flammation should not be neglected, as it may involve serious conse- 
quences. Multitudes of children have had permanent impairment or 
even loss of hearing, with caries or necrosis of the walls of the middle 
ear and of the mastoid cells, which might have been prevented by 
prompt and skilful management of the ear in the early stage of the in- 
flammation. If, therefore, the otitis continue without mitigation of 
pain after the above measures have been employed, paracentesis of the 
drumhead is probably required. The following directions for perform- 
ing this operation, which will be useful to country practitioners who may 
not be able to obtain the assistance of a specialist, are from the pen of 
Pomeroy: "The forehead mirror should be worn, in order to leave the 
hands free to operate by either artificial or day light. A good-sized 
speculum is introduced into the meatus. Then an ordinary broad 
needle, about one line in diameter, with a shank of about two inches, 
such as oculists use for puncturing the cornea, shoujd be held between 
the thumb and fingers, lightly pressed, so as not to dull delicate 
tactile sensibility. The part being well under light, the most bulging 
portion of the membrane should be lightly and quickly punctured with 
a very slight amount of force. The posterior and superior portion of 
the membrane is the most likely to bulge. The chordae tympani nerve 
ordinarily lies too high up to be wounded. The ossicles are avoided by 
selecting a posterior portion of the membrane. After puncture the ear 
should be inflated by an ear-bag whose nozzle is inserted into a nostril, 
both nostrils being closed, so as to force the fluid from the tympanum. 
The puncture may need to be repeated at intervals of a clay or two, 
provided that the pain and bulging return." 

Albert H. Buck, of New York, in a highly instructive paper read 
before the International Medical Congress in 1876, writes as follows of 



TREATMENT OF COMPLICATIONS AXD SEQUELS. 257 

paracentesis of the membrana tympani in scarlatinous otitis: "In this 
one slight operation, which in itself is neither dangerous nor very pain- 
ful, lies the power to prevent the whole train of disagreeable and dan- 
gerous symptoms.' Buck relates an instructive example : The age of 
the patient was three years, and the earache had been complained of 
only about twenty-four hours. "Toward morning," says he, " I was 

sent for, as the pain had become constant An examination with 

the speculum and reflected light showed an eedematous and bulging 
membrana tympani (posterior half), the neighboring parts being very 
red, though as yet but little swollen. In the most prominent portion of 
the membrane I made an incision scarcely three millimetres (one-tenth 
inch) in length, and involving simply the different layers of the mem- 
brana tympani. This was almost immediately followed by a watery 
discharge (without the aid of inflation), which ran down over the child's 
cheek. At the end of three or four minutes the child had ceased 
crying, and in less than a quarter of an hour she was fast asleep. At 
first, the discharge was very abundant and mainly watery in character, 
but it steadily diminished in quantity and became thicker, till finally, 
on the fourth day, it ceased altogether. On the tenth day the most 
careful examination of the ear could not detect any trace of either the 
inflammation or the artificial opening." The ear had probably been 
saved from ulceration of the drum membrane, long-continued suppura- 
tive otitis, and perhaps permanent impairment of hearing. 

When an opening has been made in the membrana tympani either by 
incision or ulceration, it is advisable in some instances to inflate the tym- 
panum by Politzer's method, which has been alluded to above. The 
nozzle of an India-rubber bag, with a flexible tube attached, is introduced 
into the nostril on the affected side, and both nostrils are compressed 
against it. The patient fills his mouth with water, which he swallows 
at a given signal, as after the words one, two, three, spoken by the ope- 
rator. During the act of swallowing, which opens the Eustachian tube, 
the rubber bag is forcibly compressed, which forces the air along the 
tube into the middle ear and facilitates the escape of the pent-up secre- 
tions in the tympanic cavity. 

If the otitis have continued unchecked by treatment until the secre- 
tions within it, after days and nights of suffering, have escaped by 
ulceration through the drumhead, the opportunity for prompt and certain 
cure is passed. Still, the patient under these circumstances may quickly 
recover, or there may be the other alternative described above, in which 
the ear is badly damaged and chronic inflammation established in the 
walls of the tympanum, giving rise to an offensive otorrhcea. In this 
state of the ear internal remedies are indicated, such as surgeons employ 
in suppurative inflammations of bone occurring in other parts of the 
system. Cod-liver oil and iodide of iron are required, especially by 
patients of strumous diathesis, the object being to promote a more 
healthy state of system, so as to prevent extension of the inflammation 
and facilitate the healing process. Carbolized solutions, as the following, 
syringed warm into the ear in which otorrhcea is occurring, are useful 
in promoting cleanliness and increasing the comfort of the patient : 

17 



258 SCARLET FEVER. 

R. — Acidi carbolici 

Glycerinoe . 

Aqua) fl lv - — Misce. 

But recently a much more effectual curative agent for local treatment 
has been discovered in boracic acid, by the use of which the discharge 
more quickly diminishes and the condition of the ear more certainly and 
rapidly improves than by the use of the carbolized mixtures. When the 
inflammation is recent and the ear sensitive and painful, the following 
prescription should be used : 

R — Acidi boracici ....... gijss. 

Morphia? sulphat. . . . . . gr. j. 

Glycerinae, 

Aqua? aaf^j. — Misce. 

Sig. — Drop one to three drops into the ear three times dialy. 

If the acute stage of the otitis have passed, with fever and pain, and 
no tenderness be present on pressure, the following prescription, which 
causes too much pain in the acute stage, will be found useful to check 
the inflammation and otorrhoea and restore a healthy state to the granu- 
lating surface: 

R. — Acidi boracici ........ 2>ij ss « 

Alcohol. # 

Aquse aa f ^j. 

Sig. — Drop one to three drops into the ear three times daily. 

The beneficial eifects observed from the use of boracic acid in aural 
surgery have given it nearly the same position as a curative agent to 
diseases of the ear which atropine holds to diseases of the eye. Recently, 
aurists are employing finely triturated powder of boracic acid dusted 
into the ear. The patient lies upon the side with the aifected ear 
uppermost. The ear is thoroughly cleaned by syringing with tepid 
water, and by means of a little scoop made of stiff paper or pasteboard 
or the segment of quill as much of the powder is introduced into the 
ear as will cover a five-cent silver piece. By working the ear it 
descends to the drumhead. I can bear witness to its efficacy in the 
otorrhoea of children when it is used in this manner three times daily. 

The following astringent has also been employed with good results for 
the otorrhoea resulting from scarlet fever as well as from other causes : 

R. — Zi.nci sulphatis, 

Aluminis . aa gr. v. 

Aquse f^j. — Misce. 

A few drops of this should be dropped into the ear, or, if the ear be 
sensitive and painful, five drops should be added to a teaspoonful of 
warm water and dropped or syringed into the ear. 

But in recent times, aurists have discovered a remedy superior to 
the above in iodoform, the action of which is safe and efficient for 
protracted otorrhoea with granulations, and it is superseding to a great 
extent the agents heretofore used in the treatment of this disease. The 
ear should first be thoroughly cleaned by syringing with warm water 



TREATMENT OF COMPLICATIONS AND SEQUELS. 259 

and dried, and iodoform, to which a little balsam of Peru is added to 
mask the disagreeable odor, should be pressed down to the bottom of the 
auditory canal by any convenient instrument. It is anodyne, astringent, 
and disinfectant, and should be employed in a dry state in considerable 
quantity. 

The sequelae of otitis media, such as granulations sprouting out from 
the drumhead, some of which may be of large size, and are known as 
polypi, may require treatment by the aurist. A polypus may some- 
times be removed by the forceps, or better by the snare. Polypi not 
large and favorably located can sometimes be cured by an astringent 
powder, as iodoform, sulphate of zinc, or alum, or by applying the liquid 
subsulphate of iron. The otitis externa produced by the irritating dis- 
charge which flows from the middle ear soon disappears when the flow 
ceases. 

The renal affection, which, as we have seen, so often commences in 
the declining period of scarlet fever, or during convalescence in mild as 
well as severe cases, is frequently more dangerous than the primary 
disease. It largely increases the percentage of deaths. A clear appre- 
ciation of its therapeutic requirements is important, since by judicious 
treatment many recover who would inevitably be sacrificed by improper 
measures. The family should be informed that the danger from scarlet 
fever does not cease with the decline of the eruption, and that the kid- 
neys may become seriously affected by too early exposure of the patient 
to currents of air or sudden changes of temperature, by which cutaneous 
transpiration is checked. He should, therefore, be kept indoor in a 
comfortable and uniform temperature three or four weeks after the ter- 
mination of the fever, until desquamation has entirely ceased and the 
•new epiderm is sufficiently thick and firm to protect the surface. During 
the changeable temperature of the autumnal, winter, and spring months 
even longer confinement at home may be advisable. 

The nephritis and consequent albuminuria antedate by some days the 
occurrence of dropsy, and a physician should never discharge a scar- 
latinous patient without one or more examinations of his urine. When 
his visits cease the nurse should be instructed to make the examinations 
by heat and nitric acid during the ensuing month, and if any evidence, 
however slight, appear that the kidneys are involved, he should be 
notified, in order that appropriate treatment may be immediately com- 
menced. Early and correct treatment of the nephritis is attended by 
much better results than delayed treatment, and many more patients 
are doubtless now saved than in former times, when little attention was 
given to the state of the kidneys until dropsy or other prominent symp- 
toms appeared. I have found no mother or nurse so ignorant that she 
could not properly employ the test of nitric acid and heat, and if she be 
solicitous for the welfare of the child, she will not hesitate to carry out 
the directions and immediately notify the physician if the tests employed 
produce the least cloudiness or turbidity of the urine. 

The patient as soon as nephritis commences, as shown by the state of 
the urine, should be put to bed in a room of warm and equable tempera- 
ture (72° to 75° F.). His diet should be liquid, consisting of milk, 
farinaceous food, and a moderate quantity of animal broths. He may 



260 SCARLET FEVER. 

drink liquids freely, especially water not too cool, to which spiritus 
aetheris nitrosi is added. If he be prostrated by the primary disease, 
alcoholic stimulants should be allowed. 

The indications are to relieve the hypenemic kidneys by diaphoresis 
and purgation. To produce the former the patient should be immersed 
in a warm bath at about the temperature of the body (98° to 100°), in 
which, if he be quiet and comfortable, he should remain from fifteen to 
twenty minutes, but if restless and frightened by the water a less time, 
after which he should be placed in a warm bed and well covered by 
blankets. If perspiration result, the bath has been useful, and it may 
be employed in grave cases two or three times daily. If perspiration 
do not result, it may be produced by surrounding the body either by 
hot dry or moist air. Hot dry air may be produced by burning alcohol 
in a thin layer upon a plate under a chair upon which the patient sits 
while he is surrounded by a blanket, or he may be covered in bed and 
the hot air introduced under the bedclothes. In New York a con- 
venient apparatus is used for this purpose, consisting of a small sheet- 
iron pipe enclosed in a small box of the same material. The box is in 
the form of a trunk, with a handle for convenience in carrying, and the 
lower end of the pipe, which extends nearly to the floor, contains an 
alcohol lamp. Hot moist air may be produced by placing against the 
patient bottles of hot water surrounded by towels wrung out of water. 
The steam arising from them and enveloping the body and limbs produces 
a prompt sudorific effect. There is in use in this city, in the treatment 
of these and similar cases requiring diaphoresis, a convenient apparatus 
for generating steam. It consists of a cylinder pierced with holes for 
the admission of air and containing a spirit lamp, over which is a pan or 
pail holding a little water. The patient, nearly naked, is placed in a chair 
with the apparatus underneath, and is covered by a blanket, so that the 
steam surrounds the body. This gives rise to free perspiration, which 
continues after the patient is placed in bed. This treatment should be 
repeated one or more times daily, according to the gravity of the case. 

The sudorific effect of the treatment by external warmth described 
above should be aided by employing diaphoretics. Those which have 
been most used are the acetates of ammonium and potassium, the bitar- 
trate and citrate of potassium, and spiritus aetheris nitrosi. If employed 
when the surface is cool, they act rather as diuretics than diaphoretics. 
These agents, being simple in their action and without deleterious effect, 
may be given frequently and in large proportionate doses for the age. 

But lately a diaphoretic which far surpasses these in efficiency has 
been discovered in pilocarpine, the active principle of jaborandi. Being 
soluble in water and tasteless, it is easily administered, and is retained 
when, on account of the ursemic poisoning present in scarlatinous 
nephritis, the stomach is irritable and other medicines, as digitalis, are 
rejected. Ether may be employed with it, or the amount of alcoholic 
stimulant may be increased at the time of its exhibition in order to guard 
against any depressing effect. To a child of two years one-fortieth to 
one-twentieth of a grain may be given every six hours by the mouth. It 
may also be employed hypodermically, as one-twentieth of a grain to a 
child of five years. It has both a diaphoretic and diuretic action, while 



TREATMENT OF COMPLICATIONS AND SEQUELS. 261 

it stimulates both the salivary and mucous secretions. According to 
one observer, an adult when fully under the influence of pilocarpine 
secretes from one pint to one quart of saliva within two hours, and 
Leyden reports a case of diphtheritic nephritis in which the quantity 
of urine rose from half a pint to five pints daily. But its most prompt 
and certain action is upon the sweat-glands. Hirschfelder speaks of its 
beneficial action in relieving various forms of dropsy, and adds : "In 
one morbid condition of the kidney, however, jaborandi is the remedy 
par excellence, and that is the acute parenchymatous nephritis which 

frequently follows scarlatina This disease heals spontaneously 

if the danger that threatens life from reduction of the urine and from 
the effusions of fluid into the cavities of the body be averted. In this 
disease jaborandi works wonders." I have also found it an invaluable 
agent when the older remedies failed and death seemed imminent. The 
following cases, in which the beneficial action of this agent was apparent, 
occurred in my practice : 

Case 8. — G , male, aged five years and six months, sickened with 

scarlet fever ou June 2, 1882. It began with vomiting, and was attended 
by a degree of febrile movement which indicated an attack of rather 
more than the average gravity. The fauces at one time exhibited a 
slight exudation like that of diphtheria. In the declining stage of the 
malady rheumatic pain aud tenderness occurred in the wrist and finger- 
joints, but not in those of the lower extremities. The case, however, pro- 
gressed favorably, and during the convalescence ray attendance ceased. 
On June 24th my attention was again called to the child, when the urine 
was found to be scanty and very albuminous. External measures, such 
as are described in the foregoing pages, were employed, and the infusion 
of digitalis with potassium acetate ordered to be given every three hours, 
but this medicine was for the most part vomited. The bowels were kept 
open by jalap and the potassium bitartrate. The urine, however, con- 
tinued scanty, and on June 28th severe convulsions occurred. At this 
time the quantity of urine was only f ,?ij in twenty-four hours. The pulse 
in the convulsions was quick and feeble, the skin very hot, and the axil- 
lary temp. 103°. The eclampsia continued one hour, and was con- 
trolled by large and repeated doses of bromide of potassium, aided by 
clysters of five grains of hydrate of chloral in water. Muriate of pilo- 
carpine was now directed to be given in doses of one-thirty-second of a 
grain every three hours, dissolved in cold water. This agent was not 
vomited, and it must have been given by the parents in the fright and 
anxiety in larger or more frequent doses than were directed, for on July 
1st the bottle containing one grain was empty. Free diaphoresis resulted 
from the pilocarpine, and the quantity of urine was increased. The 
mother stated that the child had taken only two doses, or one-sixteenth 
of a grain, of pilocarpine when the diuretic effect was apparent and free 
diaphoresis also occurred. She also stated subsequently that the quantity 
of urine was larger when the pilocarpine was administered every third 
hour than when given at a longer interval. A flaxseed poultice on which 
mustard was dusted was also applied over the kidneys. On June 20th 
the pulse was 96, temperature 100.5° ; occasional convulsive attacks 
occurred, which were readily controlled by enemata of hydrate of chloral. 
On June 30th the symptoms were all better; no more attacks of eclampsia 
had occurred, and the urine was more abundant and less albuminous. 



262 SCARLET FEVER. 

The mother remarked that the new medicine (pilocarpine) had settled 
the stomach and increased the urine. The patient continued to improve, 
and on July 4th the record states : " Now takes the pilocarpine, gr. -j^, 
every six hours ; passes urine freely since yesterday ; has not vomited 
sines he began to take the pilocarpine ; pulse 106, axillary temp. 99° ; 
is playful and takes milk freely, nearly three quarts in twenty-four 
hours, with some farinaceous food. Digitalis with potassium acetate is 
also given in occasional doses." July 6th, pulse 92, temp. 99° ; per- 
spires much, and urine nearly normal in quantity and character. 

Case 9. — Mary S , aged five years, on Dec. 22, 1882, presented the 

symptoms of severe nephritis. Her brother had scarlet fever two weeks 
previously, and she had sore throat at about the same time, but without 
efflorescence; pulse 98, temperature 98.5°; her urine highly albuminous, 
and reduced to f 3iv in twenty-four hours ; bowels constipated. .Ordered 
a single dose of 

1£. — Hydrarg. chlor. mitis . ...... gr. iij. 

Resin, podophylli . gr. £. — Misce. 

The muriate of pilocarpine was also ordered* gr. -^, but the patient 
vomited soon after taking it. Another dose was retained, and was 
followed by considerable perspiration. Dec. 23d, had one stool from the 
powder of yesterday. Has taken five does of pilocarpine, but vomited 
after three of them. The last dose was administered at 10 p. M., and the 
mother says she " sweat fearfully " during the night. The patient was 
kept warm in bed; stimulating poultices of mustard and flaxseed, one to 
sixteen, were constantly in use over the kidneys, and the pilocarpine was 
administered three or four times a day. The record for Dec. 26th states : 
"Took the pilocarpine four times since yesterday morning, and each dose 
is followed by perspiration lasting from one to one and a half hours; 
quantity of urine, from fjfvj to fgviij daily; vomited twice yesterday, not 
to-day; pulse 104; temp. 97.75°; complains of frontal headache; bowels 
regular ; has considerable salivation. The patient is warm in bed, and 
the flaxseed and mustard poultice over the kidneys is continued." Dec. 
28th, specific gravity of urine 1019 : urine still quite albuminous and 
containing blood-corpuscles and granular casts, also crystals of oxalate of 
lime. Dec. 30th, takes gr. -£$ pilocarpine twice daily, and occasional 
doses of infusion of digitalis ; urine more abundant ; it specific gravity 
1014, slightly albuminous, and containing very few granular casts and 
blood-corpuscles; has lost its smoky appearance ; reaction alkaline; per- 
spiration slight ; patient convalescent. 

In another instance, a child of five years, from three to four weeks 
after scarlet fever was noticed to have anasarca of the face and extrem- 
ities, with scanty and albuminous urine. One-thirty-second of a grain 
of muriate of pilocarpine was administered every six hours without the 
desired sudorific effect. It was then administered every four hours, 
with an increase of perspiration and urination, so that the nephritic 
symptoms were relieved and the patient apparently out of danger within 
three or four clays. 

In a fourth patient, a girl of three years, having scarlatinous nephritis, 
with symptoms very similar to those in the last case, the administration 
of one-twentieth grain doses of pilocarpine in conjunction with the hot- 
air bath, was followed by increased perspiration and urination, and pro- 



TREATMENT OF COMPLICATIONS AXD SEQUELS. 263 

gressive and rather rapid convalescence. This child had been taking 
bichloride of mercury in one-fiftieth grain doses, prescribed by a homoe- 
opathic physician, without appreciable benefit. It had been for the most 
part vomited. 

Given, as in the above cases, in moderate doses and with sufficient 
interval, pilocarpine has never in my practice had any deleterious effect, 
and I regard it as a very important addition to the remedies for the 
relief of scarlatinous nephritis. It is apparently the most useful and 
important diaphoretic for this disease which we possess. 

Cathartics, especially those of a hydragogue nature, are also very 
beneficial. Their action is more certain than that of most diaphoretics 
and diuretics, and their employment is imperatively required in severe 
or dangerous cases in which it is necessary to remove as soon as possible 
the serum or urea which endangers life. Young children or those with 
delicate stomach, and those much enfeebled by the primary disease, may 
take magnesia, either the citrate or the calcined. A good cathartic for 
ordinary cases is a mixture of jalap and potassium bitartrate. the pulvis 
jalapae compositus, consisting of one part of jalap and two of cream of 
tartar. Ten grains of the mixture may be given to a child of five years, 
and repeated according to circumstances. Its effect is increased by dis- 
solving a teaspoonful of potassium bitartrate in a gobletful of water, and 
allowing the patient to drink from it. The following is a good cathartic 
in some instances, especially if the stomach be irritable, so that the more 
bulky and nauseating catharties are rejected. Care should be taken to 
obtain a good article, as some of the podophyllin of the shops is not 
reliable : 

R. — Kesinre podophylli . gr. j. 

Sacehari 3J- — Misce. 

Ft. in chart No. v.-x. 

Sig. — Give one powder, and repeat according to circumstances. 

In the treatment of one of the cases reported above it will be recol- 
lected that the mild chloride of mercury was given with the podophyllin, 
with a good result. 

After the use of laxative agents the kidneys, being less congested on 
account of the diversion that has occurred, often begin to excrete urine 
more freely. But if the patient be anaemic or enfeebled and the symp- 
toms are not urgent, it is frequently better to avoid active catharsis, which 
more or less reduces the strength, and employ remedies of a sustaining 
character, as in the following case, which occurred in my practice : A 
little boy, pallid and scrofulous, began to have anasarca after scarlet 
fever, chiefly in the scrotum, accompanied by a moderate degree of 
ascites. The urine, which was passed in nearly the normal quantity, 
contained albumen, but not in large amount. This patient gradually 
and fully recovered, with no treatment except the use of an oil-silk 
jacket over the kidneys and abdomen to promote diaphoresis, and the 
use of iron. Such a patient, treated by the powerful eliminatives which 
we employ for the more urgent and robust cases, would probably have 
been injured rather than benefited. Xo treatment can therefore be 
recommended in a treatise on scarlatinous nephritis which will be 



264 



SCARLET FEVER. 



strictly applicable for all cases. Variations are demanded according to 
the state of the patient and the form and gravity of the disease. 

Diuretics which do not stimulate the kidneys are proper at an early as 
well as late period of the renal malady, and digitalis is the one usually 
prescribed. I do not hesitate to order it from the first day in combina- 
tion with the acetate of potassium. One teaspoonful of the infusion may 
be given every third hour to a child of five years. The following formula 
is for one of this age in good general condition : 



R . — Potass, acetatis 
Infus. digitalis 



f3 vj. — Mi see. 



The following formulae are recommended by Meigs and Pepper : 
R. — Potass, bitart gj. 



-Potass, bitart. 
Spt. junip. comp. 
Spt. tether, nitros. 
Tr. digitalis 
Syrupi 
Aquae 



fzv. 

f *ii. — Misee. 



Dose. — One teaspoonful every two hours to a child of two to four years. 



R. — Potass, acetat. 
Tr. digitalis 
Syr. scilhe . 
Syr. zingib. 
Aquse 



. f^ss. 

. f£V. 

q. s. ad. f 3 iij. — Misce. 



Dose. — A teaspoonful every two or three hours to children two or three 
years old. 

Local treatment is important. L. Thomas, Romberg, and others 
recommend the application of leeches, three or more, over the kidneys. 
Thomas says: " In many cases the abstraction of blood causes immediate 
and permanent relief; the fever and the pain in the region of the kidneys 
cease, the secretion of urine becomes augmented, the albuminuria lessens 
from day to day, and the moderate degree of dropsy that has been devel- 
oped disappears." It is only in the more robust children, who have 
been but little reduced by the primary disease, that leeching is, in my 
opinion, admissible. In the majority of cases instead of- depletion a 
poultice slightly irritating, so as to cause redness of the skin, should be 
applied over the kidneys, or for older children, not likely to be frightened 
by the process, the dry cups may be applied daily. In subacute cases, 
not attended by any alarming symptoms, sufficient redness may be pro- 
duced by one of the irritating plasters which the shops contain, constantly 
worn. 

Eclampsia, described in the preceding pages, is produced, as we have 
seen, during the course of scarlet fever by the irritating effect of the 
scarlatinous poison upon the nervous centres ; but, occurring after the 
decline of scarlet fever, it is ordinarily produced by the retained urea. 
The same remedies are required to control the convulsive movements as 
when they occur under other circumstances. The bromide of potas- 
sium should be immediately administered in large and frequent doses 
whenever eclamptic symptoms arise. During eclampsia a child of 
three years should take five grains of this agent every five to ten 



ROTHELN. 265 

minutes till the attack ceases, and then at longer intervals. The hy- 
drate of chloral is a more powerful agent, and if the eclampsia be not 
quickly controlled, I commonly employ it per rectum, dissolved in one 
or two teaspoonfuls of water. For a child of three to five years five 
grains should be thrown into the rectum by a small glass or gutta-percha 
syringe, and retained by pressure. Properly administered and retained, 
it rarely fails to control the eclampsia within ten or fifteen minutes. 
Subsequently, occasional doses of the bromide should be given to prevent 
the occurrence of eclampsia while the measures described above are being 
employed to eliminate the urea. 

Rheumatism, endocarditis, and pericarditis, arising as complications 
or sequelae, require the treatment which is appropriate when they occur 
under other circumstances, but the remedies should not be depressing, 
as the system is already enfeebled by the primary disease. The rheu- 
matism, if mild, usually abates in a few days without medication, and 
the affected joints require only some soothing lotion and support by a 
bandage. The following liniment may be applied upon muslin and 
covered by cotton wadding : 

R. — Acid, carbolici ......... fgj. 

Tine, belladonna? f]f j. 

01. camphorati f * ^ i j . 

If the rheumatism be severe and affect several joints, the sodium salicy- 
late should be prescribed, as in the idiopathic disease, with an occasional 
opiate to procure rest. 

Endocarditis and pericarditis require rest in the horizontal position, 
avoidance of all excitement, the use of the tincture or infusion of digi- 
talis or of the fluid extract of convalaria to procure a slow and steady 
action of the heart. Three drops of the tincture of digitalis or five 
minims of the fluid extract of convalaria may be given every four hours 
to a child of five years. The same external measures should be employed 
as in acute pleuritis. I prefer the application of a thin poultice of flax- 
seed containing one-sixteenth part of mustard and covered with oiled silk. 
The cardiac inflammations, as well as rheumatism, require opiates in 
sufficient doses to procure rest and sleep. 

Pleuritis, which we have stated is apt to be suppurative, demands the 
same treatment as the idiopathic disease when it occurs in cachectic 
patients. . 



CHAPTEE III. 



ROTHELN. 



The disease known as rotheln has heretofore been rare in America. 
In the Eastern continent, on the other hand, it appears to have been 
known for many years, and American physicians frequently designate 
it German or French measles. Meagre and imperfect descriptions of 



266 ROTHELN. 

this malady have appeared in some of the British journals, and cases 
quite fully detailed have been published by British physicians. 

Jiotheln is not entirely a new disease in this country, though most 
American physicians never saw a case of it until since the year 1870. 
Cases occurring in and about Boston were described by Dr. Honans, Sr., 
in 1845, and at a later date, namely in 1853 and 1871, B. E. Cotting 
and Mr. D. Howard saw cases, and described them in papers read before 
local societies. (See Boston Med. and Surg. Journal, March 15, 1873.) 
In 1874, Dr. Caleb Green, of Homer, Courtland County, New York, 
an accurate and intelligent observer, also witnessed an epidemic. 

This hitherto rare and interesting malady occurred in New York City 
as an epidemic in 1873 and 1874, attaining its maximum prevalence in 
March and April of the latter year, after which it declined, occasional 
cases occurring throughout May. This, so far as I can learn, was the 
first occurrence of rotheln in this locality. In a general practice of more 
than twenty years, extending over a considerable portion of this city, I 
had previously seen nothing like it, and other older physicians, having a 
large general practice, have informed me that they consider it an entirely 
new disease with us. Those who believe that they have occasionally 
observed isolated cases of it, previously to the epidemic, probably refer 
to roseola. 

The first case which I met with occurred in the middle of December, 
1873, in West Seventy-first Street, in the northern suburbs of this city. 
A few weeks later cases were so numerous in the more thickly populated 
section of New York as to attract the attention of many physicians. It 
was evident that a disease had appeared with which we were not familiar, 
and as the eruption occurred in points and small circumscribed patches, 
it was usually designated by the physicians, in want of a more accurate 
name, epidemic roseola, or was spoken of as a spurious measles. Physi- 
cians who were familiar with foreign medical literature saw the resem- 
blance between these cases and those of rotheln, as described by British 
and continental writers, but in certain at least of the foreign cases the 
duration of the rash was said to be seven days (Liveing, London Lancet, 
March 14, 1874, and Med. News and Library, May, 1874), whereas in 
the cases in New York it commonly disappeared by the fourth day. 
This discrepancy, however, was not sufficient to invalidate the belief in 
the identity of the New York disease with the foreign rotheln. It was 
readily explained by the difference in the seasons in which the cases 
occurred, for Liveing observed his cases in June and July, and, as we 
will see, the greater the external heat, the longer is the duration of the 
eruption. 

Between the middle of December, 1873, and May 1, 1874, I had 
observed and treated this malady in eighteen families. Cases occurred 
in three other families living in the same houses with some of those 
which I attended, and, as they were fully and clearly described to me, 
so that there could be no doubt as to their nature, I have included them 
in my statistics. The total number of cases in these twenty-one families 
was forty-eight. During May, when the epidemic was declining, I saw 
six additional cases, occurring singly, making a total of fifty -four. Their 
ages are given in the following table : 



PREMONITORY STAGE. 267 

Age. Cases. 
From eight months to one year ....... 2 

" one year to two years ........ 4 

" two years to five years ....... 16 

11 five years to ten years 23 

" ten years to fifteen years ....... 3 

11 fifteen years to thirt}' years 6 

Total number of cases . ..... 54 

The age of the youngest patient was eight months, and that of the oldest 
thirty years. Seventy-two per cent, of the total number were between 
the ages of two and ten years ; so that rotheln is preeminently a disease 
of childhood. Individuals in and beyond the middle period of life seem 
to have nearly an immunity from it. The age of the oldest patient of 
whom I was informed in the epidemic of 1873 and 1874 was about forty 
years. On March 25, 187.3, during, my attendance in the New York 
Foundling Asylum, rotheln appeared in a boy of four years; in the 
following month about thirty more cases occurred in this institution, all 
children, while among the large number of female nurses and employes, 
who were chiefly between the ages of twenty and thirty years, all but 
three escaped. 

From 1874 to 1880 rotheln did not prevail in New York, unless now 
and then an isolated or sporadic case, the nature of which was not recog- 
nized, and which was supposed to be roseola. On August 9, 1880, two 
cases appeared in different wards of the New York Foundling Asylum, 
when it was remembered that two weeks previously these children had 
been exposed to a patient in the hospital attached to the institution, 
who had what the physician in attendance supposed at the time to be 
roseola. 

Commencing with these two cases an epidemic occurred in the asylum, 
mild in type, affecting only a few at a time, but extending over several 
months, until about sixty inmates, chiefly children, were attacked. 
Toward the close of 1880 rotheln began to appear in the northern part 
of the city, in which the asylum is located, and over which my practice 
extends. Its maximum prevalence was attained in the latter part of 
March and April, 1881, when it particularly attracted the attention of 
physicians. A large proportion of the children attending certain public 
and private schools were attacked. It occurred in seventeen families in 
my practice. The ages of the patients in these families are given in the 
following; table : 

Age. Cases. 

From one to two years .3 

" two to five years 8 

" five to ten years 18 

" ten to fifteen years ........ 11 

There were two cases over fifteen years, aged respectively twenty- 
two and forty-two years 2 

Total number of cases 42 

Premoxttory Stage. — Premonitory symptoms are, in most instances, 
absent, or so mild as to attract but little attention. It not infrequently 



268 ROTIIELN. 

happened in the New York epidemics that the parents or the teachers 
in the schools were first made aware of the illness of the children by 
observing the eruption. In some instances children were sent from 
school, not because they felt too ill to remain, but on account of the 
unusual appearance of the skin. Sometimes, however, in those old 
enough to express their sensations, a premonitory stage of some hours, 
or a day, or even of longer duration, was present; consisting of such 
symptoms as usually occur when one has taken a severe cold, as lan- 
guor, pain in the head, trunk, or limbs. The resident physician of the 
New York Foundling Asylum was so ill with rotheln that he was con- 
fined to his bed during the first day of the disease. Now and then 
patients experience nausea previously to the eruption, and in the first 
and second days of the eruptive stage. In only one instance did I 
observe grave prodromic symptoms. A boy, aged eight years, was sud- 
denly seized with clonic convulsions, and while in a warm bath for the 
relief of these, the rash appeared upon those parts of the body which 
w r ere immersed in water. 

Symptoms. — Tegumentary System, (a) The Skin. — The eruption 
commonly commences upon the forehead, around the ears, and along the 
neck, as in measles. Occasionally it may appear upon the back or 
chest, as in the above-mentioned case, in which the hot water accelerated 
its appearance. Commencing above the efflorescence travels downward, 
appearing after some hours upon the lower part of the trunk and on the 
legs, resembling in this respect the eruption of measles and scarlatina. 
It occurs upon all parts of the integument, except the scalp and palmar 
and plantar surfaces. In the majority of the cases which I have seen 
it gradually faded away, disappearing by the fourth day, but in children 
who were kept warm in bed, or in warm apartments, it remained longer 
than on others. In many instances traces of the rash were still visible 
several days after recovery when the patients were heated by exercise 
or excitement. It reappeared at times, though indistinctly, on a girl 
of thirteen years, for three weeks. In most of the cases in the New 
York epidemics the eruption commonly occurred in points and circular 
spots, somewhat smaller than those of measles. These points and spots 
were numerous and thickly set, so that, in the aggregate, they covered 
at least half of the surface, while between them the skin presented nearly 
or quite its normal appearance. The general aspect jn most cases was 
more like that of measles than that of scarlatina, but in exceptional 
instances the skin between the points and spots had a redness similar to 
that of erythema, and the resemblance was very like the scarlatinous 
efflorescence. Thus, in a boy of three years, the eruption so closely 
resembled the scarlatinous over the trunk, that were it not that the 
temperature was constantly below 100°, and all febrile movements ceased 
within three or four days, I would probably have considered the malady 
a mild scarlatina. In certain patients the eruption, beginning in cir- 
cumscribed spots, like that of measles, becomes in two or three days 
confluent, so as to resemble that of scarlatina, while over other parts the 
spots remain discrete. This was the character of the eruption upon the 
third and fourth days on the extremities of a little boy in the Found- 



SYMPTOMS. 269 

ling Asylum. The rash is attended by considerable itching, from which, 
indeed, many- patients suffer more than from all other symptoms. 

The eruption disappears on pressure, produces a slight roughness of 
the surface, as ascertained by passing the fingers gently over it, and 
usually fades away without desquamation. Exceptionally, there is a 
slight branny exfoliation, and in one of my patients this was as consid- 
erable over the abdomen as in cases of scarlatina. 

(b) The Mucous Membrane. — In connection with the cutaneous erup- 
tion a mild inflammation also occurs upon the mucous membrane cover- 
ing the fauces, buccal cavity, and nostrils, and upon reflections of this 
membrane over the eyes and eyelids, i.e., upon the conjunctiva. In 
certain patients this inflammation is scarcely appreciable, but in the ma- 
jority it arrests attention at once. It produces a suffused, reddish, or 
weak appearance of the eyes, with a moderately increased lachrymation. 
On everting the eyelids the palpebral conjunctiva is seen to be injected. 
In certain patients a moderate puriform secretion collects at the inner 
angle of the eyelids. In occasional cases the conjunctivitis causes oedema 
of the lids, usually slight, and likely to be overlooked by the physician ; 
but in three instances which I now recall to mind, the mothers of the 
children directed my attention to the swollen state of the lids. In one 
of these, an infant of twenty-three months, the tumefaction was so great, 
commencing about the time the eruption began to fade, that light was 
totally excluded from the eyes, and it was impossible to ascertain their 
condition. The skin over the eyelids retained nearly its normal appear- 
ance, and a puriform secretion appeared between the lids. In three or 
four days the oedema of the lids and the hyperemia of the conjunctiva 
rapidly declined. The coryza is in most cases sufficient to cause an 
unpleasant sensation in the nostrils and provoke sneezing; but the flow 
from the nostrils, though present, was in no instance under my observa- 
tion as abundant as in ordinary cases of scarlatina, or even of measles. 
The fauces present an injected appearance, and in severe cases there is 
moderate swelling of the tonsils. The same catarrhal hyperemia is also 
seen in spots or patches, more or less diffused, upon the buccal surfaces. 
Both the faucial and buccal catarrh are less in degree, however, than in 
cases of rubeola and scarlatina, which have an equal intensity of cuta- 
neous eruption, and this fact has aided me in differential diagnosis. 

The Respiratory System. — In both the epidemics which I have wit- 
nessed the mucous membrane of the larynx, trachea, and bronchial tubes 
participated only slightly in the inflammation which involved the nasal, 
buccal, and faucial surfaces. Many of my patients had no cough, but 
others had a mild cough lasting for a few days, but with normal respira- 
tion. It was due apparently to a very mild catarrh of the respiratory 
tract at the time when the nasal and conjunctival surfaces were the most 
affected. It subsided in a few days without treatment. In no case do 
I recollect that there was any hoarseness. 

The Digestive System. — The tongue in rotheln is moist and of nor- 
mal appearance, or covered by a slight fur. The appetite may be im- 
paired, but is not wanting in uncomplicated cases. The patients some- 
times say that it is nearly the same as in health, the thirst is slight, and 
the bowels are regular. 



270 ROTHELN. 

Nausea is not infrequent, and vomiting was, in several cases in my 
practice, one of the initial symptoms. In certain patients it also occurred 
on the first or second clay of the eruption. In others there was no nausea, 
so fiir as I could learn, either immediately before or during the preva- 
lence of the disease. This symptom is less frequent in rotheln than in 
scarlet fever, but is as common apparently as in measles. I have never 
found albumen in the urine, though I have examined that passed by 
several patients. This secretion did not appear to be abnormal except 
as it contained urates, so common in febrile states. 

The Pulse and Temperature. — The largest number of accurate daily 
observations relating to the temperature was, I think, that of Dr. Reid 
in the New York Foundling Asylum during the month of March, 1874. 
He has kindly furnished me with his statistics relating to this symptom 
as follows: "The number of closely observed cases in which the tem- 
perature was taken was twenty-four. In seventeen of the cases the 
temperature ranged from 97° to 99°, in six it reached 100°, 100-J- , 
and 100}°; in one it reached 103 J° on the second day of the eruption, 
but remained so elevated only one day." In certain patients Doctor 
Reid observed what he designates, "a tendency to the development of an 
ephemeral fever." These observations correspond closely with those 
made by myself during the same epidemic. Thus, in 16 cases I found 
the axillary temperature taken each day to be constantly between 98° 
and 100°, with a pulse under 110, except in one case, in which it num- 
bered 124. In certain other patients a more decided febrile movement, 
lasting from one to two or three days, occurred, usually in the commence- 
ment of the malady. Thus, a girl aged three and a half years had a 
temperature of 101 j° and a pulse of 128. In another instance the pulse 
was 124 and the temperature 102°. In another, a girl of three and a 
half years, there was active febrile movement occurring without apparent 
cause on Saturday night, but abating on the following day. She seemed 
well until the following Tuesday, when the febrile movement returned 
and the eruption appeared. On Thursday the temperature from 102° 
to 103° fell to 99J-°, and within a day or two she was convalescent. In 
two other patients from two to four days after the disappearance of the 
eruption an accession of fever occurred, lasting about one day, and 
attended by pain and distress in the epigastric region, but without vomit- 
ing or diarrhoea. In one of these the temperature was 103f-°, the pulse 
130 per minute. In the other case the temperature and pulse did not 
seem to be under these figures, but were not accurately ascertained. 
Occasionally the febrile movement is due more to complications than to 
the primary disease. Thus, in two of my patients the febrile movement 
was mainly attributable to diphtheritic inflammation which had attacked 
the fauces. But while the fever in rotheln is ordinarily of short dura- 
tion, in certain patients temporary exacerbations may occur in which the 
temperature is as high as in scarlet fever or measles. 

Complications — Prognosis. — The only complication which occurred 
in cases in my practice has already been alluded to, namely, diphtheria, 
which, when prevalent, is apt to attack surfaces already inflamed. In 
the Foundling Asylum varicella complicated one case and pneumonia 
another. In a third pneumonia occurred about three days after the 



NATURE. 271 

disappearance of the eruption. The prognosis in uncomplicated cases 
is always very favorable, and there is no liability to sequelae more than 
in mild catarrhal inflammations of a non-specific character. The duration 
of rotheln is short, not ordinarily extending beyond three to five days. 

Nature — Incubative Period — Contagiousness. — Is rotheln a dis- 
tinct malady or one with which we are familiar, but the form and char- 
acter of which are modified by unusual meteorological conditions? Is 
it roseola assuming at certain periods an epidemic character, and appear- 
ing to be contagious ? Or is it at all times infectious, possessing a specific 
principle, and, like other infectious diseases, self-propagating? Should 
it in nosological classification be placed among the non-contagioUs and 
local, or among the constitutional and infectious maladies? Let us con- 
sider the facts observed in the New York epidemics. 

The first cases of rotheln in this city were often designated roseola by 
the physicians called to treat them, since they seemed to resemble more 
closely this disease than any other w T ith which they were familiar. But 
rotheln differs widely from the peculiar form of dermatitis known as 
roseola. The successive occurrence of the eruption over the upper and 
then the lower parts of the body, but covering the whole surface, and 
the definite duration of three to five days, are points of difference. More- 
over, roseola would not, without so great change in its character as to 
become virtually a distinct disease, occur in the cool months without any 
appreciable dietetic cause, as an epidemic over a certain area and for a 
limited time, affecting whole households and sparing other households, 
as well as individuals of a certain age. We, therefore, consider it dis- 
tinct from roseola. 

Most of the cases in the New York epidemics bore considerable resem- 
blance to measles, both as regards the appearance and duration of the 
eruption and the catarrh of the mucous surfaces. Parents often diag- 
nosticated measles before the arrival of the physician, and the physician 
himself, at first glance, sometimes made the same diagnosis. But in 
rotheln the shortness and mildness of the stage of invasion, the absence 
of cough or the presence of one trivial and scarcely noticed, appetite 
good or but slightly impaired — in fine, symptoms that are transient or 
slight, afford a striking contrast to the graver symptoms of measles. But 
the decisive proof that rotheln is not a modified measles is found in the 
fact that one does not prevent the other. Of the forty-eight cases ob- 
served by myself, prior to May 1st, in the epidemic of 1874, nineteen at 
least had had measles, and one who had rotheln took measles subsequently. 
I have already stated that in the New York Foundling Asylum rotheln 
in 1873 and 1874 closely followed an epidemic of measles. A consider- 
able number of the children attacked by the former disease had recently 
recovered from the latter. During the epidemic of 1880 and 1881 the 
^same fact was observed, namely that a previous attack of measles as well 
as scarlet fever afforded no protection from rotheln. Dr. Chadbourne, 
the resident physician, writes of the cases in the Foundling Asylum in 
1880 and 1881: "Eight children had rotheln who had had both scarlet 
fever and measles within six months under my observation, while certain 
others had had these diseases at some previous time." Of the cases 
observed by myself in family practice in the same epidemic, it is stated 



272 ROTHELN. 

in my notes that ten had had measles. These statistics are sufficient to 
show that rotheln is a distinct disease from measles, however close the 
kinship. 

That rotheln is not a form of scarlet fever is evident from the fact 
that as regards at least the New York epidemics the rash was in 
most instances quite distinct from the scarlatinous efflorescence, occur- 
ring, as we have said, in small more or less circular points and patches. 
Moreover, as we have remarked above, there is in rotheln a slight 
febrile movement and general mildness of symptoms, which contrast 
with the high fever and other pronounced symptoms of scarlatina, or if 
there 'be considerable febrile movement its duration is brief. But the 
conclusive proof of an essential difference between these two diseases is 
found in the fact already stated in reference to measles, that the attack 
of the one malady does not prevent the occurrence of the other. There 
are, it is true, cases in which it is difficult at first to make the differ- 
ential diagnosis between rotheln and mild measles or mild scarlet fever, 
but when the course of the malady has been closely observed for three 
or four days, it w r ill rarely happen, I think, that we will be unable to 
make out its character. 

Those cases of an epidemic which arise when the causes or conditions 
from which it is developed are most strongly operative and w T hich at this 
time are apt to be typical, obviously afford the best data for studying its 
nature. Such were the forty-eight cases which I saw in the epidemic 
of 1873 and 1874, and the forty-two in that of 1880 and 1881. As 
regards the former epidemic, in thirteen of the twenty-one families 
embraced in my statistics, the first cases were children, who up to the 
time of the seizure were attending public and private schools, and in 
certain instances those who were nearly simultaneously attacked, living 
perhaps in streets widely separated, were attending the same school. 
During the epidemics of 1880 and 1881, the first patients in thirteen 
of the eighteen families in which rotheln occurred in my practice were 
school children between the ages of six and twelve years, and in most, 
if not all, the different schools which they attended, rotheln was at the 
time prevailing as an epidemic, as I ascertained on inquiry. It, there- 
fore, seemed probable that these children whom I attended had con- 
tracted it from others in the schools. 

In both the New York epidemics during the time 'that rotheln was at 
its maximum prevalence, in most of the families containing two or more 
children the cases were multiple, not occurring simultaneously, but in 
succession, as if the malady was contracted from those first affected. 
This is what we daily witness in the spread of exanthematic fevers. 
Thus in Mr. E.'s family, a girl attending one of the public schools took 
rotheln in the middle of December, 1873 ; the two remaining children 
sickened with it one week and two weeks later. A niece visiting in the, 
family at the time when the first child was sick, but returning home to 
another street, also had the eruption on December 27th. Alice R., 
aged ten years, a frequent visitor at Mrs. E.'s, living in the same street, 
and several times exposed to his children during their illness, also took 
rotheln about January 4th. West Seventy-first Street, where these 
cases occurred, is thinly settled and suburban, and I could learn of no 
other cases in the vicinity. A child of Mr. P., aged five and a half 



NATURE. 273 

years, had been in the habit of playing with two children two doors 
away who became affected with rotheln in the beginning of April, 
1881. On April 14th he was supposed to have a mild coryza from 
taking cold, as he sneezed often, but in a few hours the efflorescence 
appeared. Four days subsequently on the 18th, an infant was affected 
in the same way, and thirteen days later another child in the family, 
aged twelve years. In a similar manner rotheln occurred in the families 
of two brothers living in adjoining houses in West Fifty-first Street, 
The first patient was a boy of twelve years. It appeared successively 
in the children of these two families until ten had been affected. In a 
family in West Forty-sixth Street, the first case was a boy attending a 
school in which rotheln was prevalent. Within twenty days, namely, 
between March 31st and April 20th, four other children were attacked 
in succession. 

These facts and cases seem to demonstrate the contagiousness of 
rotheln, at least during the time in which the conditions are most favor- 
able for its development, or during the time in which the epidemic 
influence is most pronounced. In the declining period of both the New 
York epidemics, the cases which I observed occurred for the most part 
singly, although there was no attempt to isolate the patients, so that the 
contagiousness of the disease, if present, must have been very slight. 

Rotheln is, in my opinion, an exanthematic fever feebly contagious. 
It resembles varicella in general mildness of symptoms, in the absence 
of dangerous complications or sequelae, and in the uniformly favorable 
prognosis, while its symptoms show a resemblance to measles and scarlet 
fever. 

If the above view be correct, rotheln must possess an incubative 
period which, in the cases observed in both epidemics, apparently varied 
between seven, or perhaps less than seven, and twenty-one days. Its 
incubation, therefore, resembles that of scarlet fever, which, as is well 
known, varies in different patients. In the cases which came under my 
notice, the incubative period, when it could be accurately ascertained, 
was more frequently about two weeks, than a longer or shorter period. 
The resident phvsician of the New York Foundling Asvlum, when the 
epidemic was prevailing in that institution, returned to his home in the 
State of Maine to a locality where rotheln was unknown. Fourteen 
days from the date of his departure he was himself affected with the 
disease in its typical form. No other case occurred at his home, where 
probably the atmospheric conditions were unfavorable. Minnie B., 
attending a school in which there were many cases, had the rash on 
April 5th. On the 23d of the same month, eighteen days afterward, 
it appeared upon the servant who was frequently in Minnie's room. 
Elizabeth C, attending a school in which rotheln was prevailing, had 
the eruption on April 17th. It commenced upon her sister thirteen 
days, and upon her mother fourteen days subsequently. 

Other cases might be cited of an apparently shorter as well as longer 
incubative period. The following note from Dr. Chadbourne, of the 
New York Foundling Asylum, bearing upon this subject, is interesting: 
"lam led to believe from my observations that the period of incubation 

18 



274 VARIOLA. 

was, in the majority of the cases, from twelve to fifteen days. The dis- 
ease has been very feebly contagious. In some cases one child would 
have rotheln while the other, nursed by the same woman, would escape. 
In two instances women had the disease, and though each suckled two 
infants the latter escaped." 

Rotheln requires no treatment. 



CHAPTER IY. 

VARIOLA— VARIOLOID. 

Variola, or smallpox, is a specific febrile affection, accompanied by 
a vesiculo-pustular eruption upon the skin. Since the discovery of the 
protective power of vaccination it has been shorn of much of its terror, 
but it is still the most loathsome and most dreaded of all the fevers. 
Two forms of this disease are recognized, depending on the fact whether 
there have been previous vaccination. If the patient have been vacci- 
nated at some period in his life, the disease, which is rendered milder 
in consequence, is designated varioloid. If there have been no vaccina- 
tion, it is called variola or smallpox. Both forms are identical in nature, 
the one communicating the other ; they differ only in gravity. 

Smallpox presents four stages : the initial, or that of invasion ; the 
eruptive ; that of desiccation ; and, lastly, that of desquamation. It is 
termed discrete when the pustules remain separated from each other ; 
confluent when they unite. This division is made according to the 
character of the eruption upon the face and hands. There are parts of 
the surface, as the abdomen, where the pustules are always discrete, 
even in the confluent form. 

Incubative Period. — During the last half of the last century inoc- 
ulation with variolous matter was extensively practised in Great Britain 
and on the Continent,- as it was found that smallpox thus communicated 
was milder than when received by infection. This operation enabled 
physicians to determine the period of incubation, which was found to be 
from eight to eleven days. When variola is communicated through the 
air, the incubative period is somewhat longer, to wit, from twelve to 
fourteen days. 

Stage of Invasion. — Smallpox begins abruptly with chilliness. In 
children of an advanced age there is often, as in the adult, a distinct 
chill. This is followed by fever and such symptoms as usually accom- 
pany febrile movement, namely, lassitude, anorexia, and thirst. In 
addition certain symptoms arise which, though not peculiar to smallpox, 
are so marked in the commencement of this disease, that they possess 
considerable diagnostic value. These symptoms, which pertain to the 
nervous system and occur in the initial stage of varioloid as well as 



STAGES OF ERUPTION. 275 

variola, are severe frontal headache, pain in the small of the back, and 
great drowsiness, sometimes with delirium. In many children convul- 
sions occur, preceded and followed by a degree of stupor which is 
almost as profound as coma. Trousseau suggests the name rachialgia 
for the pain in the back, as he believes that it is located in or around 
the spinal cord. This belief is based on the fact which he, as well as 
other observers, has noticed, that there is sometimes in connection with 
this symptom an incomplete paraplegia, indicated by numbness of the 
legs, or even inability to use them, and sometimes more or less paralysis 
of the bladder. These paraplegic symptoms pass off in a few days. 
"Vomiting is also a common symptom in this stage, and one also- of 
diagnostic value. It occurs at short intervals for twenty-four to thirty- 
six hours. The same symptom is common in scarlet fever, and not in- 
frequent in measles, but in both these maladies irritability of stomach 
is much less persistent than in smallpox ; vomiting does not occur in 
normal rubeolous and scarlatinous cases more than once or twice. 

The tongue is covered with a moist fur. If the disease is to be dis- 
crete, constipation is commonly present in the stage of invasion ; if con- 
fluent, diarrhoea is a common symptom, continuing till the fourth or 
fifth clay, or even longer. Roseola or erythema sometimes occurs in 
this stage, and this may lead to error of diagnosis, the disease being 
mistaken for one of these cutaneous affections, or even for scarlet fever. 
The symptoms in the stage of invasion are usually more violent in con- 
fluent than in discrete variola, but there are exceptions. 

Stage of Eruption. — The eruption commences about the third day, 
earlier in some cases, later in others. The average duration, therefore, 
of the first stage is somewhat shorter than in measles, but considerably 
longer than in scarlet fever. Sydenham has stated, and observations 
show the truth of the remark, that the shorter the first stage, the more 
severe the disease will prove to be ; and, conversely, the longer the 
period, the milder will be its form. Therefore, if the eruption begin on 
the second clay, it will, as a rule, be confluent ; if not till the fifth or 
sixth day, it will be scanty and the disease light. 

The eruption commences in minute red spots, somewhat like those of 
lichen, which gradually enlarge. It is first observed around the lips and 
upon the neck, then upon the face, scalp, upper part of chest, arms, and 
finally upon the lower part of the chest, the abdomen, and legs. It is 
sometimes, especially in young children, first observed in the folds of 
the skin, as about the genitals or in the groin. If the cuticle be irritated, 
as by a sinapism, the eruption often appears first upon this part of the 
surface and in greater abundance than elsewhere. Commencing in a 
minute reddish point, as stated above, it rapidly enlarges, and soon its 
central part begins to be indurated and raised. It feels round and hard 
to the finger, is tender, and its diameter does not ordinarily exceed two 
lines. This is the papular stage. The papulse increase and become more 
elevated, and in twenty-four to forty-eight hours from the commence- 
ment of the eruptive stage they become vesicular. On the fifth day of 
the eruption, or eighth of the disease, the vesicle has attained its full size. 
Its diameter is then about one-fourth of an inch, and its elevation is two 
or three lines. Its base is circular and indurated, and it is surrounded 



276 VARIOLA. 

by a narrow zone of inflammation, indicated by redness and tenderness 
of the skin. The pock commonly, as it passes from the papular to the 
vesicular stage, loses its acuminate form, and becomes depressed in the 
centre, but in most cases, mixed with the umbilicated vesicles, are some 
which remain acuminate. 

In proportion as the eruption becomes developed in discrete variola 
and in varioloid, the symptoms which accompanied the stage of invasion 
abate; the fever, headache, pain in the back, and thirst cease, and the 
appetite returns. In the confluent form, the febrile action continues with 
little abatement. 

Simultaneously with the eruption upon the skin, an eruption also occurs 
upon the buccal and faucial surfaces, and often upon that of the air-pas- 
sages. It occurs sometimes, also, upon the conjunctiva, producing dan- 
gerous ophthalmia, and even ulceration, with loss of sight, and upon the 
mucous surface of the genital organs. The form which it presents upon 
mucous surfaces is somewhat different from that upon the skin. There 
is at first a deposit of fibrin, producing a small, round, grayish spot at 
the point of eruption — firm, slightly elevated, and covered, if not by the 
entire mucous membrane, at least by its epithelial layer. Ulceration 
soon occurs, as in ulcerous stomatitis, and, if the patient live, the repara- 
tive process succeeds, as in simple ulcers. The eruption upon mucous 
surfaces increases considerably the suffering of the patient, in conse- 
quence of the tenderness of the ulcers; and if its seat be the surface of 
the larynx or trachea, it may be the immediate cause of death, especially 
in young children, by obstructing respiration. 

The cutaneous eruption has been traced to the vesicular stage. On 
or about the fifth day of the eruptive period, or eighth of smallpox, the 
vesicles gradually change their character, their contents becoming thicker 
and turbid. At the same time they increase still more in size, and the 
central depression disappears. This is designated the stage of matura- 
tion, or of suppuration, though it is known that the turbidity is due 
chiefly to another substance than pus. The pock having undergone these 
changes, is termed the pustule. 

In discrete variola, and in varioloid, the fever returns during the pus- 
tular stage; or, if the form of the disease be confluent, and the fever have 
continued, it now becomes more intense. The return of fever, or its in- 
crease, is denoted by increased frequency of pulse, elevation of tempera- 
ture, dryness of skin, anorexia, and thirst. A tendency to constipation 
remains throughout in varioloid and discrete variola; in the confluent 
form diarrhoea more frequently occurs, which, if it continue, is an un- 
favorable prognostic sign. 

Other changes occur. The pustules increase somewhat in size, and 
become more globular. Some of them, when most distended, break 
through friction of the clothes, or scratching of the child, and their 
contents escaping, add to the loathsomeness of the disease. There is 
in the pustular stage more or less redness of the surface between the 
eruptions, and, except in the mildest cases, tumefaction from sub- 
cutaneous infiltration occurs. In the confluent form, at this period, the 
features are often so swollen that the friends would not recognize the 
patient. The eyelids may be so cedematous that the eyes are for a 



STAGE OF DESICCATION. 277 

time concealed from view. This oedema of the surface is not altogether 
absent in the vesicular stage, but it increases during the time of matura- 
tion, after which it subsides. 

Stage of Desiccation. — This immediately succeeds the full develop- 
ment of the pustules. The liquid portion of the contents of the pustules 
which are broken, evaporates, leaving a crust. If there be no rupture, 
the liquid is absorbed and a scab results, which, though smaller, preserves 
in a measure the form of the pustule. While the pustule desiccates, the 
surrounding inflammation rapidly abates. The crusts occur first upon, 
the face, and on other parts in the order in which the eruption appeared. 
The odor from the patient, at this time, is peculiar. In the confluent 
form, especially, it is very offensive, and can be noticed at a distance 
from the bedside. Rilliet and Barthez call it nauseous and fetid. As 
desiccation progresses, the symptoms, local and general, abate. The 
pulse and temperature, if the case be favorable, return to their normal 
standard. The cough, hoarseness, and thirst disappear, while the appe- 
tite returns ; the sleep is more tranquil, and the functions, generally, 
are more regularly performed. 

The last stage is that of desquamation ; it commences between the 
eleventh and sixteenth days. The scabs, which present a dark or brown- 
ish appearance, are successively detached. This period lasts several 
days ; sometimes two or three weeks even elapse before all the crusts 
separate. In the mean time the patient gradually recovers his health and 
formar strength. After the fall of the crust, the cicatrix underneath 
presents a reddish appearance. The color gradually fades, and there 
remains an irregular depression, or pit, of a lighter color than the sur- 
rounding surface; and if there have been a full development of the 
eruption, disfiguring the patient for life. 

Such is the clinical history of variola, when it is favorable, and its 
course is regular. The disease is sometimes irregular. In rare instances 
the eruption occurs almost at the commencement of the attack. The 
form is then very apt to be confluent. There are irregularities, also, in 
consequence of diarrhoea, hemorrhages or other complications. I have 
known the eruption appear first on the limbs, and last on the trunk and 
face, and the appearance of the eruption is not always the same. In 
the anaemic and feeble child it often presents a pale color, with some 
induration at its base, but without the red areola around it, or with this 
quite indistinct. In rare instances the vesicles have a reddish color, 
their contents beins; tinned with blood. This form of variola is desig- 
nated hemorrhagic. It indicates a profoundly altered state of the 
blood. The eruption in this form is of small size, and if the pock is 
broken, blood oozes from it. 

I have met one, perhaps two cases of malignant hemorrhagic small- 
pox, as described by Hebra, among the rare forms of this malady. The 
second case died so soon that we were undecided whether he had small- 
pox or scarlatina. A man aged 36 years, previously healthy, became 
suddenly and severely sick, in June, 1881, w r ith fever, intense headache 
and backache, great depression of the vital powers, sleeplessness, and a 
sensation of sinking or depression in the epigastrium. He had a 
marked foreboding of coming evil, and begged almost constantly for 



278 VARIOLA. 

relief. Within forty-eight hours a heavy and continuous dusky scarla- 
tiniform eruption covered the whole surface, except below the knees, 
disappearing on pressure ; fauces at first but moderately injected. On 
the following day, the third of his sickness, with a temperature of 
104.5°, the efflorescence became a dark red, numerous small extravasa- 
tions of blood had occurred under the skin, the urine contained blood, 
and finally seemed to consist almost entirely of dark blood ; a large 
effusion of blood under the entire conjunctiva of either eye prevented 
closure of the eyelids, and probably hemorrhages had occurred within 
the eyes, as the sight was nearly lost. Death occurred on the following 
day. In Hebra's article on smallpox is the description of precisely 
such cases, but the death of my patient was too early for exact diagnosis. 

Varioloid. — The course of varioloid is similar to that of variola, 
but it is somewhat shorter. It commences with rigors, followed by 
fever, headache, pain in the back, vomiting, drowsiness and sometimes 
delirium, or even convulsions. The symptoms in the stage of invasion 
are, indeed, the same in character, and often nearly as severe as in 
variola. With the initial symptoms, there is also sometimes a scarlatini- 
form eruption, so that the disease may at first be mistaken for scarlatina. 
On the third or fourth day the variolous eruption commences. The 
number of pocks is commonly few, often not more than twelve to twenty. 
In the mildest form of varioloid, if the physician be not summoned in 
the stage of invasion, he is not apt to be called at all, so that the patient 
may pass through the disease in ignorance of its nature. The true 
character of the malady is not ascertained till others are affected, either 
with variola or varioloid. 

The eruption pursues a more rapid course in varioloid than in the un- 
modified disease. By the fifth or sixth day the pustules are fully devel- 
oped, though often smaller and less likely to be ruptured than in variola. 
Often, in varioloid, the eruption aborts. It remains papular two or 
three days, and then declines, or it may reach the vesicular stage, and 
decline without pustulation. 

The constitutional symptoms in varioloid abate with the commence- 
ment of the eruptive stage. The secondary fever is slight or absent. 

Such is the usual mild course of varioloid, but not always. If sev- 
eral years have elapsed since the vaccination, its protective power is 
greatly impaired, and varioloid may then exhibit as severe a form as 
ordinary smallpox. In some instances it is fatal. 

The term varioloid is, as has been stated, applied to cases of variolous 
disease if there have been previous vaccination. It is also applied by 
writers to second attacks, whether the first occurred from infection or 
from variolous inoculation, but such cases are rare. 

Mode of Death. — Death in smallpox occurs in several different 
ways. The most fatal period is the pustular. Feeble children not 
infrequently die from exhaustion at or about the time that the pustules 
attain their greatest size. The eruption appears and becomes developed 
as usual, but there are evidences of weakness in the patient, and sud- 
denly the progress of the vesicle or pustule ceases. It begins to sub- 
side, and its walls shrivel. There is evidently absorption, in part, of 
the liquid contents. These phenomena are of the gravest character. 



COMPLICATIONS. 279 

Death is the common result, and within twenty-four hours. In other 
cases death occurs from apnoea. The pock increasing in size in the 
larynx and trachea, obstructs inspiration, or there may be the formation 
of a pseudo-membrane, as in true croup. This is not an unusual mode 
of death in young children, in whom the calibre of the larynx and 
trachea is small. Sometimes convulsions and coma occur in the last 
hours of life. In other cases the stage of desquamation is reached, but 
convalescence does not occur. The patient each day becomes more ansemic 
and feeble, and finally death results from failure of the vital powers. 
Again, after smallpox has run its course, purpura hemorrhagica may be 
developed. Hemorrhages occur from the gums, throat, nostrils. Blood 
is vomited, and evacuated in the stools. I have known death to occur 
in all these ways, but that from purpura is least frequent. Sometimes, 
as in scarlet fever, death occurs suddenly and unexpectedly in con- 
fluent, and even in discrete variola, when the previous symptoms had 
apparently been favorable. The patient is overpowered by the intensity 
of the virus. 

Anatomical Characters. — In those who have died of variola, with- 
out inflammatory or other complication, the heart-clots have been found 
small, dark, and soft. The blood is dark and thin. The vessels of 
the brain and its membranes are injected, so that numerous red points 
appear on the cut surface of this organ. The vessels of the lungs and 
the abdominal organs are congested, while the muscles present a deep 
red color. The variolous eruption penetrates more deeply than that 
of any other exanthematic fever. It has been stated elsewhere that it 
occurs not only on the skin, but often on the surface of the mouth, 
fauces, and air-passages. The mucous membrane in these situations is 
frequently also the seat of catarrhal inflammation, being thickened and 
softened, and in some parts, as the larynx, a pseudo-membrane is occa- 
sionally produced, as in croup. 

The eruption very seldom, perhaps never, appears upon the gastro- 
intestinal surface, but the solitary follicles and patches of Peyer are 
often enlarged, as in some other zymotic affections. The liver, spleen, 
and kidneys are commonly congested in those who have died of variola. 
The spleen, especially, is increased in volume and softened; the kidneys 
are enlarged, as from commencing nephritis, and sometimes softened. 

The minute structure of the pock is described by Rilliet and Barthez, 
and others. The vesicle is multilocular, consisting of at least five or 
six compartments, with distinct partitions. Its centre is united by 
fibrous bands to the derm beneath, which union gives rise to the umbili- 
cated appearance. The giving way of these minute bands in the pustular 
stage occurs when the form changes from the umbilicated to the convex. 
In the pustular stage also, according to some, a fibrinous formation occurs 
within the pustule; according to others, this substance is of the nature 
of the epidermis, presenting the appearance of the cuticle when macerated. 
Mixed with this epidermic or fibrinous formation are pus-cells. 

Complications. — There are several different complications of variola. 
One is salivation. This is common in the adult, but rare in the child. 
When it occurs in the child, it is slight, commencing with or about the 



280 VARIOLOID. 

time of the eruption, and disappearing in from one to four or five days. 
Ophthalmia is another complication. Simple conjunctivitis, often quite 
intense, may occur in consequence of pustules developed under the lids. 
This inflammation subsides without injury to the eye, as the primary 
disease abates. A more serious inflammation occurs at an advanced stage 
of variola, commencing in or near the desquamative period. This pro- 
duces more or less chemosis, and sometimes opacity or ulceration of the 
cornea. A similar inflammation may occur in the ear, giving rise to otor- 
rhoea, and even, in some patients, to rupture of the drum of the ear. 
Abscesses in the subcutaneous connective tissue have been occasionally 
observed, especially in the confluent form. Subcutaneous infiltration and 
feebleness of constitution favor their occurrence. Suppuration within the 
joints is a somewhat rare complication or sequel, rendering convalescence 
protracted, if, indeed, the case be not fatal. 

M. Beraud has published a memoir to show that orchitis in the male 
and ovaritis in the female may complicate variola. These inflammations 
are believed to be accompanied by a small and imperfect variolous erup- 
tion upon the tunica vaginalis and the peritoneal covering of the ovary. 
Trousseau states that he has often met this complication in the male, 
since his attention was called to it. It is mild, and subsides with the dis- 
appearance of the eruption. Laryngitis, simple or diphtheritic, bronchitis, 
pneumonia, pharyngitis, purpuric hemorrhages, gangrene of the mouth 
or other parts, oedema pulmonum, and oedema glottidis are occasional 
complications, some of which are frequent, others rare. 

Prognosis. — This depends on the age, vigor of system, form of the 
disease, and the presence or absence of complications. The younger the 
child, the greater the danger. Trousseau says: "Confluent variola, and 
even discrete variola, are almost always fatal in individuals less than two 
years old. ' ' Above the age of three or four years discrete variola usually 
ends favorably, but the confluent form is still, as a rule, fatal. Varioloid 
in the child is a mild disease, terminating favorably in a large propor- 
tion of cases. It is milder at this age than in the adult, on account of 
the more recent period of vaccination. If varioloid be severe, and the 
eruption abundant in a child who has been vaccinated, it is probable that 
the vaccination was spurious. 

It is not necessary, from what has been said, to specify the favorable 
prognostic signs. The unfavorable prognostics are, % great violence of 
the initial symptoms; early appearance of the eruption; an abundant 
eruption, especially if pale, and without swelling of the surface ; rapid 
decline of the eruption in the vesicular or pustular stage ; hemorrhagic 
eruption, or hemorrhages from the surfaces ; fever continuing after the 
appearance of the eruption ; diarrhoea persisting beyond the third or fourth 
day ; delirium or great drowsiness ; a frequent and feeble pulse ; and, 
finally, obstructed respiration — if slow, indicating a pseudo-membrane 
or variolous eruption in the larynx or trachea; if rapid, indicating bron- 
chitis or pneumonia. 

Diagnosis. — The diagnosis cannot be made with certainty prior to the 
eruptive stage. If, however, smallpox be prevalent, if the patient have not 
been vaccinated, and the symptoms which pertain to the period of inva- 



TREATMENT. 281 

sion be present, as headache, pain in small of back, repeated vomiting, 
drowsiness, and perhaps convulsions, there is ground for the gravest sus- 
picion. If, in addition to these symptoms, reddish points begin to appear 
on the second or third day, the diagnosis may be made with confidence. 
At this early period, even before there is any distinct cutaneous erup- 
tion, ash-colored spots may sometimes be observed on the buccal or 
faucial surface, the commencement of the variolous eruption ; these pos- 
sess considerable diagnostic value. 

The scarlatiniform efflorescence, in the first stage of variola, sometimes 
leads to the belief that the disease is scarlet fever. The absence of the 
pharyngitis, and the appearance of the variolous eruption soon after the 
efflorescence, correct the diagnosis. Smallpox has, in the beginning of 
the eruptive period, sometimes been mistaken for measles. The points 
involved in the differential diagnosis have been presented in treating of 
that disease. After the development of the eruption, it may be mistaken 
for varicella. The eruption of varicella, is, however, preceded by symp- 
toms which are milder and of shorter duration, and its appearance is 
different. It is irregular, instead of round ; is not umbilicated, and it 
does not have the round, inflamed, and indurated base which character- 
izes the variolous eruption. The eruption of ecthyma is sometimes um- 
bilicated, but the symptoms of ecthyma and variola, and the progress of 
the eruptions in the two diseases, are very different. 

Treatment. — Smallpox, like the other essential fevers, is self-limited, 
and therefore the constitutional treatment should be sustaining and pal- 
liative. In the first stages of the disease, the diet should be simple ; 
gentle laxatives and refrigerant drinks are required if there be much 
febrile excitement. Lemonade is a grateful drink, and may be given in 
moderate quantity. Spiritus mindereri in carbonic acid water may be 
allowed. As the disease advances, more nutritious food should be recom- 
mended; and in severe cases carbonate of ammonium, and even alco- 
holic stimulants, are required. 

As confluent smallpox is nearly always, and the discrete form often 
fatal in infancy, the physician should carefully watch the progress of the 
case in the infant. By judicious treatment, some, in this period of life, 
may be saved, who otherwise would perish. In the infant depressing 
measures should be avoided. A laxative may be given, at first, if there 
be much fever, and the bowels are constipated ; but the diet should be 
nutritious, and many soon require tonics and stimulants. If the pulse 
become more frequent and feeble, or if, with frequency of the pulse, the 
face and extremities become cool ; or, in the vesicular or pustular stage, 
the eruption suddenly subside, alcoholic stimulants must be immediately 
employed, or the patient dies. 

Such is an outline of the constitutional treatment required in small- 
pox. Sydenham inculcated a mode of treatment which experience has 
shown to be injurious in infancy and childhood. He had observed that 
the severity of the disease was ordinarily proportionate to the amount 
of eruption, and concluded from this fact that measures which retarded 
the development of the eruption were salutary; cold drinks, a cold 
apartment, scanty covering of the body, cathartics that caused deriva- 
tion of the blood from the surface, even sometimes the abstraction of 



282 VARIOLOID. 

blood, were considered, according to Sydenham's theory, to be useful 
as means of preventing full development of the eruption. 

Sydenham's treatment, however appropriate it might sometimes be in 
case of robust adults, is unsuitable for children, because they do not, 
as a rule, tolerate, in this disease, measures which reduce the strength. 
Moreover, smallpox is rendered more dangerous by what Rilliet and 
Barthez designate perturbating treatment — treatment which renders it 
abnormal. The regular appearance and development of the eruption 
are requisite in order that the case may progress favorably. On the 
other hand, the opposite plan of treatment, which families, if left to 
themselves, are apt to adopt — namely the employment of measures to 
promote perspiration, as hot drinks, and confinement in a heated room — 
is also injurious. 

The patient should be kept in a temperature such as he has been ac- 
customed to, and such as is agreeable to him ; his diet should be simple 
and nutritious ; laxative medicine should only be given to procure the 
natural evacuations. In smallpox, as in all infectious diseases, free 
ventilation of the apartment is required. 

AYhile the general eruption should not, as a rule, be interfered with, 
it is proper to endeavor to diminish, so far as possible the size of the 
pocks, on parts exposed to view, so as to prevent disfigurement. Pro- 
fessor Flint, in his Treatise on the Practice of 3fedicine, has published 
an excellent summary of the various measures which have been recom- 
mended for accomplishing this end. First : The opening and breaking 
up of the vesicle by means of a fine needle. This is tedious practice in 
confluent variola, but it can readily be performed in the discrete form — 
at least as regards the vesicles upon the face. This treatment was pro- 
posed by Rayer, and it is recommended by many who have tried it. 
Secondly : After the evacuation of the liquid, the cauterization of the 
vesicle by a pointed stick of nitrate of silver. Rilliet and Barthez say, 
in reference to this mode of treatment, " Individual cauterization of the 
pustules is, on the other hand, an almost infallible means of causing 
them to abort. To be successful, it is necessary to penetrate into the 
interior of the pustule with a pointed crayon of nitrate of silver in order 
to cauterize the derm. . . . It is only the first or second day of 
the eruption that it (cauterization) has certain success; nevertheless, 
we have often seen it succeed the third or the fourth day, or even the 
fifth." 

Thirdly : The application of tincture of iodine once or twice daily 
over the eruption when in the papular stage. Some writers, wmo have 
employed iodine, state that it does not prevent pitting but diminishes it. 
Its favorable effects are produced by coagulating the contents of the papule. 
Fourthly : The exclusion of light and air by means of a plaster. A 
mixture containing tannate of iron has been employed for this purpose 
in one of our hospitals. This produces a black mask. Light and air 
may also be excluded by smearing the face with sweet oil, and dusting 
twice daily upon the oiled surface a powder containing equal parts of 
subnitrate of bismuth and prepared chalk. Fifthly : The application 
of mild mercurial ointment upon the face or other parts of the surface, 
where it is desirable to render the eruption abortive. This mode of 



VACCINIA. 283 

treatment does diminish the size of the vesicles and the pitting, but I 
should not recommend it for children. I have known in the adult severe 
mercurialization from its employment for four or five days, and, though 
young children do not exhibit so readily the effects of mercury, the 
use of the ointment, unless for a very limited period, increases, in my 
opinion, their feebleness, and diminishes the chance of their recovery. 
Calamine made into a paste with sweet oil is said to be equally effectual 
with mercurial ointment, and it produces no constitutional effect. Its 
effect is obviously similar to that of the bismuth and chalk employed 
with sweet oil as stated above. Also, I have employed pulverized 
charcoal made into a thm paste with sweet oil or glycerine, and applied 
daily or tw r ice daily to the face. It effectually excludes the light, and 
the result appeared to be good as regards pitting, but it is a disagreeable 
application. Curschmann recommends as preferable to any of these 
methods, the use of iced compresses to the face and hands, The pain, 
redness, and swelling are diminished by their use, but without change 
in the copiousness of the eruption. (Ziemssens Encyclop.) If fissures 
or excoriations occur, an application may be made of oxide or carbonate 
of zinc in glycerine, one drachm to the ounce. 

The prevention of smallpox, so far as practicable, is one of the im- 
portant incidental duties of the physician. Isolation of the patient, 
and precautions in reference to his clothes and bedding, are imperatively 
required, so great is the contagiousness of this disease. The only 
certain means of prevention is vaccination, and providentially the in- 
cubative period of the vaccine disease is less than that of variola. 
Therefore, smallpox may be prevented after the virus is received in 
the system, by timely and successful vaccination. Vaccination, at any 
period between the time of exposure and the commencement of the 
symptoms of invasion, will either prevent the occurrence of smallpox 
or modify it. If the symptoms of invasion have already commenced, it 
is uncertain whether it produces any modifying effect. 



CHAPTBE Y. 

VACCINIA. 

Vaccinia is a mild eruptive disease, which occasionally occurs among 
cattle, and has been propagated from them to man. It is characterized 
by the appearance upon the surface of one or more papules, w 7 hich soon 
become vesicular, and then pustular. It is communicable by contact, 
but, unlike the other eruptive fevers, it is not contagious through the air. 
It is inoculable, both by the liquid contained in the vesicle, which is 
designated vaccine lymph, and by the scab which results from the desic- 
cation of the pustule. 



284 VACCINIA. 

To Gloucestershire, England, the honor belongs of discovering and 
utilizing the fact that vaccinia, a mild and comparatively harmless dis- 
ease, is transmissible from the cow to man, and that it affords protection 
from smallpox. It appears that a vague opinion prevailed among the 
farmers of this dairying section, that a disease, which has since been 
designated vaccinia, was occasionally received from the cow in milking, 
the virus passing from a pustule on the teat to a sore or chap on the 
hand of the milker, and that those who thus contract the disease receive 
immunity from smallpox. As usually happens with important discov- 
eries, so slow of apprehension is the human intellect, these people, to 
whom Providence had revealed a most important fact, were blind to its 
real value. Finally in the year 1724, Benjamin Jesty, whom the world 
has not sufficiently honored, "an honest and upright man," according 
to his epitaph, a farmer of Gloucestershire, had the courage to vaccinate 
his wife and two children. His excellent moral character did not shield 
him. He was regarded by his neighbors as an inhuman brute, who had 
performed an experiment on his own family, the tendency of which 
might be to transform them into beasts with horns. 

This first essay in vaccination appears to have been entirely successful, 
but the prejudice against the operation continued. A fifth of a century 
passed, during which there was no extension of the benefits of this great 
discovery. At last, toward the close of the last century, Dr. Edward 
Jenner, a physician of Gloucestershire, an inoculator of his district, 
began to investigate this disease of the cow, about which little was 
known, and the grounds for the belief that it afforded protection from 
smallpox. Fortunately for the world, Jenner had been educated under 
John Hunter, and had learned from his great master to study nature 
rather than books, to be guided by experience and observation rather 
than by the dogmas of his predecessors or of the schools. 

Jenner performed his first vaccination on the 14th of May, 1796, 
twenty-two years after Benjamin Jesty had lost his good name among 
his neighbors by vaccinating his own family. The popularizing of 
vaccination, mainly through Jenner's perseverance, affords one of the 
•most interesting and instructive chapters in the history of medical 
science. How he went up to London, full of the importance of the dis- 
covery, and was there advised by his medical friends to desist from his 
wild schemes, lest he should injure the reputation which he had gained 
from a creditable paper on the habits of the cuckoo ; how he was finally 
allowed to vaccinate in hospital wards, and gained some adherents to 
the new faith among the leading physicians of the metropolis ; and, 
finally, how, as the claims of vaccination began to be recognized, at 
the close of the last century and commencement of the present, a most 
acrimonious discussion arose, which filled all the medical journals of that 
period. The opponents of vaccination resorted to every device to pre- 
vent the acceptance of Jenner's views. They attempted to prejudice 
the people against them by specious arguments, by ridicule, and even 
by caricatures. One of the leading journals contained the picture of a 
cow covered with sores, and devouring children, and it was urged that 
vaccination was a bestial operation, degrading man to the level of the 



VACCINIA. 285 

brute. But the truth had gained a firm hold, and the practice of vac- 
cination extended. 

The discovery of vaccinia, and of its protective power, cannot be too 
highly appreciated. It has, probably, done more to relieve human 
suffering than anv other discovery of the last one hundred years, unless 
Ave except that of anaesthetics, and more to save human life than any 
other instrumentality of a purely physical kind. 

The fact was established in the time of Jenner, that the virus of 
smallpox inoculated in the cow produced vaccinia, which, in its propa- 
gation back to man never returned to its original form, but always re- 
mained vaccinia. Moreover, Jenner believed that the disease known in 
the horse as the grease was identical in nature with vaccinia in the cow. 
He foiled, however, in his experiment to communicate vaccinia from the 
horse, but other experiments have been more successful. In 1801, a 
Dr. Loy, of the county of York, England, met two cases of vaccinia in 
persons who had taken care of a horse affected with the grease, and, 
from the lymph which he obtained, was able to produce vaccinia in the 
cow. In 1805, Viborg, a Danish veterinary surgeon, after many fail- 
ures, succeeded also in communicating vaccinia to the cow by means of 
the virus taken from a horse. 

From this time little light was thrown on this subject till within the 
last twenty years. Although Loy and Viborg, and perhaps a few 
others, had recorded their success, other experimenters had failed to com- 
municate vaccinia from the horse. In the absence of additional cases 
the profession began to question whether there might not have been 
some error in the observations of the gentlemen whose names I have 
mentioned, and whether a disease identical with vaccinia occurred in the 
horse, or a diease which might communicate vaccinia to the cow or to 
man, was still regarded as undetermined. 

Observations confirmatory of those of Loy and Viborg were at length, 
however, made, which must be regarded as conclusive. In 1856, in the 
department of L'Eure-et-Loir, France, M. Pichot was consulted by a 
boy who had on the back of his hands vaccine pustules, which had ap- 
parently reached the eighth or ninth day. He had not taken care of nor 
been in contact with a cow, but had a few days before taken care of a 
horse affected with the grease. Vaccination was performed by means 
of the lymph taken from these pustules, and genuine vaccinia was 
produced. 

Again in 1860, an epidemic prevailed among the horses in Biemes 
and Toulouse, France. A mare sickened with the disease, and there 
was swelling of the hough, with discharge of sanious matter. M. Dela- 
fosse vaccinated two cows with this matter, and communicated genuine 
vaccinia. This epidemic was believed by the veterinary surgeons to be 
an eruptive fever, differing in its nature somewhat from the disease or 
diseases which have ordinarily been designated the grease. It has been 
conjectured that two or more distinct affections of the horse have the 
same appellation, one of which, it is now admitted, is identical with vac- 
cinia of the cow, and may communicate it ; and the reason why so many 
experimenters have failed to vaccinate the cow from the horse is that 
they have used the virus of the wrong disease, or have taken virus from 



286 VACCINIA 

horses which had been affected with the true disease, but from ulcers 
which had lost their specific character. 

Prior to the time of Jenner variolous inoculation was practised in most 
civilized countries, since variola produced in this way was found to be 
milder than when arising from infection. This practice is now obsolete; 
forbidden in some places by legislative enactments. It is superseded by 
vaccination. Vaccination, or the introduction of vaccine lymph into 
the system, is quickly and conveniently performed by scarifying with a 
lancet, and rubbing into the incisions the lymph, or a" little of the scab 
pulverized and dissolved in a drop of cold water. It may also be per- 
formed by scraping oif the epidermis with the edge of the instrument till 
the blood begins to ooze ; and also, though with less certainty of success, 
by puncturing the skin with the point of the lancet, or by an instru- 
ment called the vaccinator. The scab should never be employed when 
it is possible to obtain pure lymph, since it contains animal matter apart 
from the virus, and may be the medium through which other diseases 
may be communicated. Besides it is much less active than pure lymph. 

If the child have a vascular ngevus, this may be selected as the point of 
vaccination. Unless of large size, it can usually be cured by the in- 
flammation which vaccinia produces. Statistics collected by Simon, as 
well as Marson, show that of those who contract varioloid, the larger 
the number of vaccine cicatrices the milder the disease, and the less the 
proportionate number of deaths. In Simon's statistics of those who 
stated that they had been vaccinated, but who presented no cicatrix, 
21f per cent, died ; of those who had one cicatrix, 7 J per cent, died ; 
of those who had two, 4J- per cent, died ; of those who had three, If 
per cent, died ; while of those who had four or more cicatrices, only f 
per cent. died. These statistics would seem to indicate the propriety of 
vaccinating in several places. But, so far as appears, when two or more 
cicatrices were observed, the patients may have been vaccinated at differ- 
ent times, at intervals, perhaps of several years, and if so, the inference 
would not follow that more complete protection is produced by vaccinat- 
ing in several places than in one. Moreover, if vaccination be performed 
in the usual manner by several incisions on the arm, and the virus be 
fresh and active, usually two or more distinct vesicles arise, which unite 
in their development and probably protect the system as much as if they 
were separated by a wider space. 

Appearances — Symptoms. — In genuine vaccination no effect is ob- 
served, except the slight inflammation clue to the operation, till the close 
of the third day. Then the specific inflammation commences. This is 
indicated by a small red point, at first scarcely visible, indurated and 
slightly elevated, as determined by the touch, rather than by the eye. 
This increases, and on the fifth day the cuticle over the inflamed part 
begins .to be raised by a transparent and thin liquid. The vesicle 
increases in diameter, and by the sixth day presents an umbilicated ap- 
pearance, and is surrounded by a faint and narrow red zone. At the 
close of the eighth day the vesicle is fully developed. Its size varies 
considerably. It is usually from a sixth to a third of an inch in di- 
ameter, and oval or circular. If the vaccination have been performed 
by incisions, the size of the matured vesicle may be considerably larger, 



ANOMALIES, COMPLICATIONS, AND SEQUELS. 2S7 

and its shape irregular, in consequence of the union of two or more 
vesicles. The eruption now presents a whitish or pearl-colored appear- 
ance, due to the whiteness of the cuticle, and the transparence of the 
liquid underneath. If the vaccination be performed by incisions, it is 
not unusual to observe over the centre of the vesicle, and adhering to it, 
a small yellowish scab, which has resulted from the scarification, and 
which contains none of the virus. 

The vaccine vesicle, like that of variola, consists of compartments, 
commonly eight often, with complete partitions, so that there is no inter- 
communication. On the ninth day the inflamed areola becomes more 
distinct, and its diameter rapidly increases. Its color is deep red, its 
temperature is considerably elevated, and it is accompanied by more or 
less induration of the subcutaneous tissue, and it is tender to the touch. 
On the tenth day the pock has reached its full development. The 
areola then extends from one to two inches away from the vesicle, be- 
coming fainter at its outer circumference, and gradually disappearing in 
the healthy skin. The shape of the outer circumference of the areola 
is irregular, projecting further at one point than another, though its 
general form is circular. 

On the tenth day, when the inflammation has reached its maximum, 
the heat, itching, and tenderness in and around the pock are such that 
the child is often feverish and restless. Occasionally the glands of the 
axilla become swollen and tender. In other cases, in which there is 
but a moderate amount of inflammation, the constitutional disturbance is 
slight. 

At the close of the tenth day, or on the eleventh, the inflammation 
begins to decline ; the areola becomes narrower and then disappears ; 
the induration and tenderness abate; and with this change the pustule 
desiccates, its liquid is absorbed, and there results a brownish or a dark 
mahogany-colored scab, which is detached, ordinarily, between the four- 
teenth and twenty-first days. The cicatrix, at first reddish, like all 
recent cicatrices, gradually becomes paler, and remains whiter than the 
surrounding integument. It presents several minute depressions or 
pits, which indicate the genuineness of the vaccination. 

The theory that smallpox becomes vaccinia by passing through the 
heifer, as we have given it above, has for many years been undisputed. 
But recently the theory has been promulgated that vaccinia and variola, 
instead of being forms of the same disease, are essentially distinct; 
that w T hen the heifer is inoculated with the virus of smallpox the dis- 
ease which is produced is a modified smallpox but not vaccinia, which 
occurs as a spontaneous disease among cattle. It may be that the old 
theory, which no one doubted until recently, is wrong, but that vacci- 
nation prevents smallpox, just as a mild attack of scarlet fever prevents 
a severe attack of the same disease, shows, in my opinion, a close rela- 
tionship between vaccinia and the severe malady which it prevents. 
We wait for more conclusive facts in support of the new theory, before 
accepting it. 

Anomalies, Complications, and Sequels. — The vesicle is often 
broken, accidentally, or by the nails of the child. If the top of the vesi- 
cle be destroyed, or most of the compartments be opened, the inflamma- 



288 VACCINIA. 

tion is commonly increased, considerable suppuration occurs, and there 
results a large, irregular, yellowish scab, consisting of the virus mixed 
with desiccated pus. This scab is entirely unreliable, and unfit for the 
purpose of vaccination, though the protective power of the disease is 
not diminished by injury of the vesicle, even if it be totally destroyed. 
The cicatrix which results from extensive injury of the vesicle is apt to 
be large, and without the indented points which characterize the normal 
cicatrix. 

In rare cases when the inflammation which surrounds the vesicle is 
intense and deep seated, suppuration occurs in the subjacent connective 
tissue, giving rise to an abscess. This abscess is commonly of small 
size, but it increases the fretfulness and constitutional disturbance which 
attend vaccinia. This subcutaneous suppuration occurs most frequently 
in those who have a scrofulous or vitiated state of system. Inflamma- 
tion of the lymphatic glands of the axilla I have spoken of as not in- 
frequent in vaccinia. This sometimes proceeds to suppuration, produc- 
ing an unpleasant, though not serious, complication. 

It sometimes happens that vesicles appear in other parts besides the 
points where the virus was inserted. These supernumerary vesicles 
commonly occur where the cuticle has been removed by scalds or injuries. 

Trousseau relates the case of an infant whom he had vaccinated. On 
the eleventh day he was astonished to find twenty-seven vaccine pustules 
on the face, trunk, and limbs. This infant had, however, before the vac- 
cination, a simple non-specific eruption over the whole body, and it was 
believed that it had produced these vaccinations by transferring the 
lymph, with its nails, to the various parts where the cuticle was denuded. 

It is not unusual, also, to observe minute papules appearing on parts 
of the surface simultaneously with or soon after the vesicle, and in a few 
days declining. These seem to be abortive vaccine eruptions. 

One of the most serious complications is erysipelas. This may occur 
directly from the operation, or from the inflammation caused by the 
vesicle, when the virus possesses no deleterious property ; and again, it 
may result from some unknown element in the virus. It may occur 
immediately after the operation, when it commonly prevents the working 
of the virus, or during the vesicular or pustular stage; or, again, after 
desiccation and separation of the scab. I have observed it at all these 
periods. 

Erysipelas, occurring as a complication of vaccinia, is invariably 
referred by the friends to the virus employed, and the physician who has 
had the misfortune to vaccinate is often unjustly blamed. In many of 
these cases there is a strong predisposition to erysipelas at the time 
of the vaccination, and the operation or the inflammation which accom- 
panies the normal development of the visicle serves simply as an excit- 
ing cause. Erysipelas would occur as soon from a non-specific sore ; 
indeed, we not infrequently are called to cases of this disease in young 
children, Avhich commence from non-specific sores upon the genitals, or 
on one of the limbs. That the fault is not in the virus employed, is 
evident from the fact that other children, vaccinated with the same, have 
simple uncomplicated vaccinia. 

Sometimes, on the other hand, the cause of erysipelas, whatever it 



SUBSEQUENT VACCINATIONS. 289 

may be, exists in the virus. For further facts in reference to this subject, 
the reader is referred to our remarks on erysipelas. 

The fact is established by many observations that syphilis is communi- 
cable by vaccination. The symptoms of it may not appear till vaccinia 
has terminated, or for a little time subsequently, but it then constitutes 
a very serious sequel. A physician of this city, well known in this 
community as skilful in the diagnosis and treatment of skin diseases, 
and therefore not likely to be mistaken as regards the nature of the dis- 
eases, states that he communicated syphilis to two infants by vaccinating 
with the same scab. Both had the characteristic syphilitic eruption. 
In January, 1868, an infant was brought to Prof. Alonzo Clark's clinique, 
in this city, having syphilitic rupia, which, in the opinion of the physi- 
cians present, was undoubtedly the result of vaccination. 

Trousseau relates the case of a young woman, eighteen years old, who 
was vaccinated with virus taken from an infant apparently in perfect 
health. The vaccination was unsuccessful ; but twenty-three days subse- 
quently his attention was called to an eruption which had appeared in 
two places on the woman's arm, corresponding with the points where the 
virus had been inserted. The eruption was that of ecthyma, which, by 
the next examination, which was five days subsequently, had been trans- 
formed into rupia. The axillary lymphatic glands were tumefied and 
indolent, and finally roseola appeared, which removed all doubts as to 
the syphilitic character of the disease. There was syphilitic infection, 
which first manifested itself in the points where vaccination had been 
performed {Article de la Vaccine). It is not ascertained in Professor 
Clark's case, nor is it stated in Trousseau's, whether the lymph or scab 
was employed for vaccination. There can be little doubt that the pure 
lymph never communicates anything but vaccinia, and if by vaccination 
any other disease be imparted, a little blood has mingled with the lymph,, 
or the" scab has been employed. 

The vesicle in genuine vaccinia is sometimes very small, not having 
a diameter of more than two lines. Occasionally the development of 
the vesicle is retarded. It does not appear till two or three days later 
than the usual time, or even a longer period. 

Vaccinia is modified by certain diseases. It is arrested by measles 
and scarlet fever, pursuing its course after the subsidence of the exan- 
them. On the other hand, it sometimes modifies the paroxysmal cough 
of pertussis, but only during the time when the pock is maturing. Ecza- 
matous eruptions occasionally occur after vaccinia, as they often do after 
the other eruptive fevers, or, if already present, they may be aggravated. 

Subsequent Vaccinations. 

A second vaccination, performed prior to the ninth day after the first 
vaccination, is successful. A genuine vaccine eruption results, which 
is smaller the more advanced the primary disease. This second eruption 
overtakes the first. On the ninth day the susceptibility to vaccinia is, 
in most cases, lost ; so that vaccination performed on the tenth, or sub- 
sequent days, is unsuccessful. 

As a rule, an acute contagious disease occurs only once in the same 

19 



290 VACCINIA. 

individual. Vaccinia is an exception. In most people, after a few 
years, it can be produced a second time; and cases of a third or fourth 
successful vaccination, at intervals of a few years, are not uncommon. 
Now, subsequent cases of vaccinia differ from the first, which has been 
described above. The period of incubation is shorter, and the vesicular, 
pustular, and desiccative stages succeed each other more rapidly, so that 
the whole period of the disease is less. The variation from the appear- 
ance and course of the first vesicle is proportionate to the degree of pro- 
tection which the first vaccination still affords, both as regards smallpox 
and vaccinia. If several years have elapsed since the first vaccination, 
and the protective power which it affords is nearly lost, the second 
vaccinia differs but little from the first. If, on the other hand, the first 
vaccination still afford nearly complete protection, the result of the second 
is slight; the eruption is insignificant, lacking the characteristic appear- 
ance of the vaccine vesicle, resembling a common sore, and disappearing 
within a week. It is not accompanied by the inflamed areola, or any 
appreciable constitutional disturbance. 

Vaccination often produces no result. This is sometimes due to the 
fact that the lymph or scab employed is useless. It has spoiled by keep- 
ing, or never has been good. In other cases it is due to a lack of suscep- 
tibility in the person. Some take vaccinia with difficulty, and only after 
several vaccinations ; just as children, though fully exposed, often fail 
to take measles or scarlet fever, on account of a condition of the system 
which prevents the reception of the virus, or antagonizes and controls 
its action. In some instances, after vaccination, an eruption is produced, 
which may or may not be genuine ; but it immediately becomes purulent, 
and is soon broken. A large yellow, uneven scab results, having none 
of the appearance and containing little or none of the vaccine virus. 
This scab, as well as the liquid matter which preceded the formation of 
the scab, is utterly useless for the purpose of vaccination, and, if so 
employed, will probably cause a sore from its irritating effect, but not of 
a specific character. If, in place of the true vaccine vesicle, the eruption 
present the appearance which I have described, namely, that of a pustule, 
soon breaking and forming a large irregular, yellowish scab, the vaccinia 
— if it be correct so to designate it — must be considered spurious. A 
sore has been produced by the animal matter which was employed in the 
vaccination along with the virus, which has modified the action of the 
virus, and probably has rendered it useless as a means of protection ; or 
there may have been no virus inserted with this animal matter. The 
physician should in such cases insist on a second vaccination. 

Cases like the above are of frequent occurrence, and the parents of 
the child are often satisfied with the result. They see an eruption 
following vaccination, accompanied by considerable inflammation, and 
leaving a cicatrix. "Unless undeceived by the physician, they are apt to 
remain in the belief of the child's security, until, perhaps, it takes small- 
pox. Such cases, obviously, tend to diminish the confidence which the 
public should have in vaccination as a means of protection from small- 
pox, and on account of their frequent occurrence it is important in every 
case that the physician should see the result of his vaccination. It 
has been proposed, as a means of determining the genuineness of vaccinia, 



KEVACCINATION. 291 

to revaccinate when the eruption begins, and if the first be genuine, the 
second will overtake it. This is called Brice's test ; but it is not neces- 
sary, since the physician, familiar with the appearance of the true vesicle, 
can determine at once its genuineness by the sight. 



Protection from Vaccination — Revaccination. 

It was believed by the early advocates of vaccination that the general 
performance of this operation would soon eradicate smallpox from the 
community, so that it would be interesting only to the medical historian 
as a scourge of past ages. This result, however, is not achieved. As 
a rule, the greater the benefit of any measure designed to ameliorate the 
condition of mankind, the greater and more numerous are the obstacles 
which diminish its effectiveness. Science is full of examples of this. 
Fortunately these obstacles, as regards vaccination, are not such as to 
impair the confidence of physicians in its protective power, and it is not 
too much to expect that this simple operation will yet be the means of 
rendering smallpox a disease almost unknown, unless in its modified 
form. 

Vaccination should be performed in the first year of life. In rural 
districts where there is little danger of exposure to smallpox, it may be 
deferred till the age of ten or twelve months. In the city, on the other 
hand, where there is constant intercourse of people, and where contagious 
diseases are often contracted in ignorance of the time and place of 
exposure, an earlier vaccination is advisable. Some physicians recom- 
mend performance of the operation as early as the age of four or six 
weeks. The objection to this is, that if erysipelas occur, so young an 
infant is apt to perish from it, whereas an infant three or four months 
old ordinarily recovers. For this reason I believe that the most suitable 
age is about four months for the city infant, in ordinary times ; but if 
smallpox be epidemic, vaccination should be performed at an earlier age. 
I have vaccinated even the newborn infant when smallpox had broken 
out in adjoining apartments. 

Vaccinia usually extinguishes, for a time, the susceptibility to small- 
pox. According to Mr. Gintrac, varioloid does not occur within two 
years in those who have been vaccinated. It may, however, in excep- 
tional instances, occur in a mild form within a few months after vaccina- 
tion. The protection afforded by vaccination gradually diminishes by 
time, but it does not probably, as a rule, cease entirely. Varioloid, 
however, occurring thirty or forty years after a successful vaccination, is 
apt to be severe, and it may even be fatal, showing that it has been but 
slightly modified. In other cases, even after so long an interval, the 
symptoms present a degree of mildness which indicates that the protec- 
tive power of the vaccination is not entirely lost. 

If a second vaccination be practised soon after the scab from the first 
vaccination has fallen, it will usually produce no result, but in other 
cases it gives rise to a little redness, swelling, and induration, which 
show that vaccinia has been reproduced, though in a very mild and 
insignificant form. It is probable that in these cases varioloid might 



292 VACCINIA. 

also occur by exposure, though with a mildness corresponding with that 
of the vaccinia. The longer the period after the first vaccination, the 
greater the number of those in whom a second vaccination is effective, 
and, as has already been stated, the greater also the liability to the 
variolous disease, until the system is protected by a second vaccination. 
A second vaccination should be performed about the sixth or eighth year, 
and a third between the fifteenth and twentieth years. If smallpox be 
epidemic, it is proper to vaccinate all who have not been vaccinated 
within three or four years. 

Selection of Virus. 

The lymph is preferable to the scab for vaccination, provided that it 
can be obtained fresh. The scab is more easily preserved, and, there- 
fore, if the lymph and the scab be old, the latter is to be preferred. The 
lymph should be taken on the fifth day, if the vesicle be sufficiently de- 
veloped. It may also be taken on the sixth, seventh, or even eighth 
day, provided that the areola have not formed. The lymph of the fifth 
day acts with greater energy, though that of the sixth or seventh day 
is not much inferior. Lymph obtained after the formation of the 
areola is less efficient, though it may communicate the genuine disease. 

There is no mode of vaccination so reliable as the use of lymph taken 
directly from the arm and immediately inserted — the arm to arm vacci- 
nation. Lymph can be preserved for a few days on a flattened surface 
of whalebone, or the segment of a quill, and if employed within a week, 
it will usually communicate vaccinia Lymph may be preserved a longer 
period between two surfaces of glass, but the best way of preserving it 
is in capillary glass tubes. The end of the tube is placed within the 
vesicle, and the lymph ascends by capillary attraction. When a suffi- 
cient quantity is received, the ends are sealed, by holding them for a 
moment in a flame. Care is requisite in doing this so as not to heat the 
lymph, as it is spoiled by a temperature much above the body. When 
the lymph is used, the ends of the tube are broken, and by blowing 
gently through it a sufficient quantity is received on the point of a 
lancet. 

If the scab be genuine, it presents a dark brown or mahogany color, 
and has a circular, oval, or at least a rounded form ; it is firm, or com- 
pact, and has a lustre. Soft, yellowish, and irregular scabs are not genu- 
ine, and those of a dull appearance, or without lustre, have usually 
spoiled in the keeping. The scab is best preserved in soft beeswax, 
which excludes the air, and it should be kept in a cool place. It is the 
belief of many that the vaccine virus gradually becomes weaker by pass- 
ing successively through the human system (Condie, American Journal 
of the Medical Sciences, April, 1865), and that therefore different spe- 
cimens of virus work with different energy, according to the degree of 
removal from the cow. To what extent this view is correct is not fully 
ascertained, but, certainly, if the virus employed continue to produce a 
small vesicle, attended only by a little inflammation, there is reason to 
believe that the protection which it imparts is less than that from virus 
which works with greater energy, and it should be exchanged for such. 



VARICELLA. 293 

In New York we are able to obtain at any time lymph directly from the 
heifer. It has never passed through human blood, for the original lymph 
came from cattle in one of the provinces of France, where vaccinia was 
prevailing epidemically. The popular objection to vaccination is obvi- 
ated by the use of this lymph, but it works with great energy, produc- 
ing a large pock, and a sore which is often a month in healing. I have 
found it very reliable, and prefer to use it in ordinary cases. 



CHAPTEE VI. 

VAEICELLA. 

Varicella, chickenpox, or swinepox, is the shortest and mildest of 
the eruptive fevers. It is highly contagious, so that few children escape 
who are exposed to it. Its period of incubation is from fifteen to seven- 
teen days. It is not inoculable, or at least those who have attempted to 
inoculate with the lymph of varicella have failed. I endeavored to com- 
municate the disease in this way some years ago, but without result. It 
attacks the same individual but once, and it occurs as an epidemic. It 
has been thought by some to prevail most immediately before, during, 
or after epidemics of smallpox, and it has been conjectured that it is a 
modified form of variola, and hence its name, which signifies little 
variola. This idea is, however, entertained by few, and it is opposed by 
the following facts : Varicella may occur after variola, or variola after 
varicella, without any modification, and the two diseases are very dis- 
similar as regards gravity of symptoms and duration. The variolous 
disease, whether smallpox or varioloid, often occurs in the adult ; vari- 
cella, on the other hand, is a disease of infancy and childhood. I have 
seen one adult case, which I recall to mind, and Professor Flint states 
that he has also observed it, but its occurrence at this period of life is 
rare. Moreover, varicella and variola have been known to occur simul- 
taneously in the same individual. Such a case was reported by M. 
Delpech, in a memoir published in 1845. 

Symptoms. — Varicella usually commences with such symptoms as 
usher in ordinary mild febrile attacks, namely, headache, languor, chilli- 
ness, and sometimes aching in the back and limbs. Fever supervenes, 
which is usually moderate, the pulse rising perhaps to 100 or 112, and 
the thermometer showing an increase of temperature, but less than occurs 
in the other eruptive fevers. These symptoms which precede the erup- 
tion are sometimes absent, or are so mild as to escape notice. The fever 
usually ceases on the second day, but it may return on the following 
night. The appetite is rarely lost, and most children continue, more or 
less, at their amusements. 

When the above symptoms have continued about twenty-four hours, 



294 VARICELLA. 

the eruption appears first over the trunk and soon afterwards over the 
face and limbs. It consists of minute disseminated papules, which be- 
come vesicular in the course of a few hours. The occurrence of the 
vesicular stage is nearly simultaneous on all parts of the surface. The 
vesicles lack the hard indurated base of the variolous eruption, though 
they are sometimes surrounded by a faint zone of redness. They differ 
also from the variolous eruption in the absence of umbilication, and in 
irregularity of shape. Some are small and acuminate, some hemispheri- 
cal, and of medium size, and others oval or elongated, and of large size. 
The inflammation is quite superficial, not involving the subcutaneous 
tissue, and scarcely affecting the deepest layer of the skin. 

The vesicles vary in size from the diameter of half a line to that of 
even three lines. They occasionally give rise to slight itching. On 
the second day of the eruption, or third day of the disease, they are still 
fully developed, their liquid contents being nearly transparent. At the 
close of this day the liquid begins to be somewhat cloudy, and its absorp- 
tion commences. On the fourth day of the disease desiccation pro- 
gresses rapidly, and by the fifth the liquid has for the most part disap- 
peared, and a scab results, small, thin, and of a yellowish-brown color. 
The scabs are soon detached, the redness which 1 indicated their seat 
disappears, the epiderm which had been raised and removed by the 
eruption is reproduced in its normal state, and in a few days all evi- 
dence of varicella is effaced. A cicatrix occasionally results, but it is 
due not to the simple varicellar eruption, but to a sore produced from 
the eruption by the scratching of the child. 

The number of vesicles varies considerably in different cases. They 
are never, so far as I have observed, confluent ; but they are sometimes 
so abundant in young children, that, if the disease were variola, it would 
be called severe discrete. They occur also on the buccal and faucial 
surfaces, where they soon break, forming small ulcers. 

Diagnosis. — Obviously the only diseases with which varicella is 
liable to be confounded are such as present vesicles at some stage of 
their course. From the local vesicular eruptions this disease is diag- 
nosticated by the fact that the vesicles appear on all parts of the sur- 
face. It is sometimes mistaken for variola or varioloid, or vice versa — 
a mistake very damaging to the reputation of the physician. The 
points of differential diagnosis are the symptoms ' of invasion — severe, 
and lasting three or four days in the one ; mild, and continuing only 
one day in the other — an eruption passing slowly through its stages 
from the papulae, to the pustulae, umbilicated, with circular, raised, and 
inflamed base, appearing first on the face and neck, and not till a day 
later on the legs, in the one disease ; while in the other the evolution, 
shape, and course of the eruption, as described above, are materially 
different. By proper attention to these distinctive features it is rarely 
difficult to diagnosticate the two diseases. 

The prognosis in varicella is always favorable. It does not, of itself, 
endanger life, nor seriously incommode the patient ; nor does it give 
rise to complications or sequelae. The treatment, therefore, is the 
simplest possible. Mild diet, and a laxative, may be prescribed during 
the febrile period ; but nothing further is required. 



SECTION III. 

NON-ERUPTIVE CONTAGIOUS DISEASES. 



CHAPTEE I. 

DIPHTHERIA. 

DIPHTHERIA is a disease of antiquity, dating back at least as far as 
the commencement of the Christian era. Aretseus, at the close of the 
first century after Christ, described the Malum JEgyptiacum as a 
malady which occurred chiefly among children, and was characterized 
by a white concretion, spreading over the tonsils, a fetid breath, and in 
some patients by a return of food through the nostrils, and by great 
dyspnoea, ending in suffocation. Since the commencement of the six- 
teenth century, numerous epidemics of it have been observed in Europe 
and America, and at the present time it is one of the most common and 
fatal epidemic maladies in both continents, while in many localities, 
especially in large cities, it is established as an endemic. 

Age. — Diphtheria is preeminently a disease of childhood, a large 
majority of the cases occurring between the ages of two and ten years. 
Under the age of one year the younger the child the less the liability 
to it, and it rarely occurs prior to the fourth month. The age of the 
youngest patient in my practice, so far as I recollect, whose disease was 
undoubtedly diphtheria, was three months and a few days ; but in one 
instance, I observed upon the fauces of an infant of six weeks, whose 
brother had just died of diphtheria, a few white specks, like grains of 
salt, over each tonsil, which disappeared in three or four days, without 
the occurrence of any marked symptoms, by the application of a solu- 
tion of chlorate of potassium. Certain physicians, having charge of 
maternity wards, have observed a disease, occurring in newborn infants, 
which bears some resemblance to diphtheria, but which, if it be true 
diphtheria, presents anomalous features. Thus, Dr. W. S. Bigelow 
reports in the Bost. Med. and Surg. Journ. for March 11, 1875, ten 
cases, occurring between September and December, 1873, in the Boston 
Lying-in Asylum, all fatal but two. The prominent symptoms and 
anatomical characters were: dark hue of skin, hematuria, pseudo- 
membranous exudation upon certain mucous surfaces, dark green stools, 
spleen enlarged and dark, kidneys engorged, and in some of the cases 
effusion of blood into the pelves of these organs, and along the urinary 
tract, brownish casts in the renal tubes, etc. 

Dr. Bigelow refers to what appears to have been similar cases in one 

(295) 



296 DIPHTHERIA. 

of the continental asylums, and I have met one case in some respects 
similar, which I saw with Dr. Ewing, of New York. Malignant diph- 
theria appeared in a family in West Fifty-third Street, in the middle of 
October, 1880. The patient, a boy of ten years, died, and the remain- 
ing two children, as soon as the nature of the malady was apparent, 
were sent from the house. Nevertheless, one of these, precisely seven 
days after the removal, was attacked by diphtheria of the hemorrhagic 
form, and died in less than one week. Blood escaped from the nostrils, 
fauces, under the skin in numerous places, causing purpuric spots, and 
from the kidneys or urinary tract, causing hematuria. 

The mother, who was at this time in the sixth month of pregnancy, 
continued greatly depressed by the occurrence, although she was robust, 
and her general health good. She had been in constant attendance 
upon her children. Her infant, born three months subsequently to the 
occurrence of diphtheria in her family (February 6, 1881), was well 
developed, but it presented a similar hemorrhagic cachexia to that in 
the second case of diphtheria. Blood escaped from the vessels under 
the skin, causing blotches and prominences, and from the mucous sur- 
faces. The bleeding was especially persistent and copious from the 
umbilicus, so that death occurred in less than a week. The mother 
had at no time any diphtheritic symptoms, yet we know that the diph- 
theritic poison is subtle and penetrative, producing its peculiar inflam- 
mation upon the uterine walls of the parturient woman, even when her 
fauces are not affected. Nevertheless the etiological relation of diph- 
theria to cases like the above is uncertain, and can only be determined 
by more numerous observations, and thorough examination. In the 
epidemic observed by Dr. Bigelow, so far as appears from the published 
account, the mothers, and other inmates, were not affected with diph- 
theria, and this must give rise to grave doubt whether the malady 
affecting the infants were really diphtheritic. Diphtheria is infrequent 
after the middle period of life, and old age appears to possess nearly an 
immunity from it. 

Incubation. — It is only in exceptional instances that we are enabled 
to ascertain the incubative period of diphtheria. I was enabled to fix 
it very nearly in the following cases which occurred in my practice. A 
boy of nine years was in the same room, about one hour on Saturday, 
with a child who had fatal diphtheria. On the ' following Tuesday, 
without any other exposure, he sickened with a malignant form of the 
same disease. Mrs. E. assisted in nursing a fatal case of diphtheria, 
from November 11 to 13, 1874, after which she returned home, several 
blocks away. On the evening of the 15th she complained of sore 
throat, and on the following day the diphtheritic pseudo-membrane was 
observed over her tonsils. On the 19th the exudation had disappeared, 
and she was convalescent. On the 20th her sister, residing with her, 
and who -had not been elsewhere exposed, was similarly affected, and 
after three or four days she convalesced. The only other case in the 
family, a boy, sickened with diphtheria on December 2. In the first 
of these cases the incubative period seems to have been from two to 
four days ; while in the last, it was apparently longer. In April, 1876, 
a little girl died of malignant diphtheria in West Forty-first Street, 



NATURE. 297 

New York City. Her sister, aged one year, remained with her from 
April 11 to IT, when she was removed to a distant part of the city, and 
placed in a family where there was no sickness, and had been no diph- 
theria. On the night of April 24, seven days after her removal, this 
infant was observed to be feverish, and on the following day, when I 
was called to examine her, the characteristic diphtheritic patch had 
begun to form over the left tonsil. In April, 1875, two sisters, aged 
seven and five years, resided with their parents, in a boarding-house, in 
West Twenty-second Street, Xew York. A playmate in the same 
house had symptoms which were supposed to be due to a cold, but which 
were diphtheritic, when one night severe laryngitis occurred, and ended 
fatally the same day. The physician who had been summoned, diag- 
nosticated diphtheria, and the two sisters were immediately removed to 
a hotel. But seven days subsequently, diphtheria commenced in the 
older child. The younger was then removed to a distant part of the 
same hotel, but on the sixth or seventh day subsequently she also 
became affected with a fatal form of the disease. It is seen that the 
period of incubation in diphtheria, like that in scarlet fever, varies in 
different cases. It is from two to eight days, with perhaps an occa- 
sional case outside these limits. 

Nature. — Diphtheria resembles scarlet fever in certain particulars ; 
in its incubative period, as we have seen above, in its variability of type 
from a very mild to a malignant form, in the common seat of its inflam- 
mations, namely, upon the fauces and nasal passages, in the profound 
blood-poisoning and prostration in the graver cases, and in the frequent 
occurrence of nephritis as a complication or sequel. It resembles both 
scarlet fever and smallpox in the fact that it is communicable both 
through the atmosphere and by contact or inoculation. It resembles 
erysipelas in the variableness of its duration, and in the fact that one 
attack does not protect the system from another. In its etiology it 
resembles typhoid fever, for it is not only communicable from person to 
person, but it is produced by foul exhalations, as sewer gases. But 
while there are certain resemblances, it is distinguished from all these 
infectious diseases by marked peculiarities. 

Diphtheria is primary or secondary. The secondary form most fre- 
quently occurs during epidemics of the other infectious diseases, and as 
a complication of them. Those infectious maladies which are accompa- 
nied by inflammation of the fauces and air-passages, are most liable to 
this complication if they occur in a locality where diphtheria prevails ; 
the inflammations of the mucous surfaces accompanying them being 
transformed into the diphtheritic. In Xew Y^ork, scarlet fever beyond 
any other disease appears to furnish the conditions which are most 
favorable for the occurrence of diphtheria, and if these maladies be 
epidemic in the same locality, not a few of the scarlatinous patients are 
affected with diphtheria in the latter part of the first, or in the second 
week, though the converse seldom happens, that a patient with diph- 
theria contracts scarlet fever. The other infectious diseases, which are 
most liable to the diphtheritic complication, are measles, variola, whoop- 
ing cough, and typhoid fever, the bronchitis of these diseases changing 
to a pseudo-membranous inflammation. 



298 DIPHTHERIA. 

It is an interesting fact that in a patient suffering from diphtheria, 
the specific inflammation is apt to occur upon such surfaces as are already 
the seat of inflammation. A catarrhal inflammation however produced 
is liable, under the influence of the virus, to become diphtheritic and 
pseudo-membranous. Thus, if I recollect correctly, four children in the 
New York Foundling Asylum have had diphtheritic conjunctivitis, 
occurring upon trachoma, and Billroth remarks " catarrhal conjuncti- 
vitis, which is so very common, may become diphtheritic" (Surg. 
Pathol., translated, page 267). All who have seen much of diphtheria 
are familiar with instances in which a catarrhal inflammation, as from a 
burn, blister, or wound, as from tracheotomy, becomes diphtheritic. 
This general fact, in regard to the nature of diphtheria, and its mode of 
manifestation, namely, that in one affected by diphtheria the diphthe- 
ritic inflammations appear by preference upon such surfaces as are 
already inflamed, has an important practical bearing. In frequent 
instances during epidemics of diphtheria, I have known careful and 
experienced physicians suppose that they were treating catarrhal inflam- 
mation of the air-passages, when suddenly indubitable signs of diphthe- 
ritic disease occurred, usually with a fatal ending. They were obliged 
to confess to the friends of the patients that they had erred in diagnosis 
and prognosis, and their reputation was sometimes seriously compromised. 
Probably, in a certain proportion of such cases, there was a change of 
a non-specific catarrhal to a diphtheritic inflammation, such as occurs 
in scarlatinous angina or rubeolous laryngitis in those who contract 
diphtheria. 

The frequent occurrence of epidemics of diphtheria during the last 
thirty years, and the great mortality which has attended them, have 
awakened an interest in this malady which has led to a careful study 
of its causes and nature. Till recently these inquiries were entirely 
clinical, but during the last few years a new line of investigation has been 
followed, namely, that of experimenting on animals, the results being 
observed by the microscope ; and while it has led to the confirmation of 
facts already ascertained, important discoveries have been made, and 
more important ones are probably in waiting. Among those who have 
taken the lead in this new field of investigation are Oertel, Buhl, and 
Hueter, of Germany. These microscopists, and several other experi- 
menters of equal reputation who uphold their views, believe that they 
have discovered the cause of diphtheria, with a high power of the micro- 
scope, standing, as Oertel says, " on the very borders of the visible," 

This discovery is so important, not only in itself, but from the promise 
which it gives of the results of future research, and from the stimulus 
which it imparts to such inquiries, that a brief statement of the facts in 
reference to it cannot fail to be interesting at the present time, when 
diphtheria is so prevalent and fatal in this city and country. The minute 
objects which the observers alluded to have discovered in patients affected 
with diphtheria, and which they suppose cause the disease, are endued 
with life and motion. They belong to the class of microscopic vegetable 
parasites which have been designated bacteria. The bacteria have been 
divided by Cohn into four genera, with species ; but only two of these, 
it is thought, sustain a causal relation to diphtheria, namely, the sphero- 



NATURE — CAUSES* 299 

bacterium or spherical bacterium, or, as Oertel designates it, the micro- 
coccus; and secondly, though in less degree, because less numerous, 
though coexisting with the other form, and penetrating the tissues with 
it, the micro-bacterium, or rod-like bacterium. 

The microscope, in the hands of various observers, has revealed the 
following important facts relative to diphtheria: In every tissue which 
is the seat of diphtheritic inflammation, and in every diphtheritic pseudo- 
membrane, the spherical bacteria occur in immense numbers, accom- 
panied by a smaller number of the other kind. In severe cases, in which 
the system is infected, they occur also in the blood. Ordinarily, as the 
symptoms of diphtheria become more grave, a proportionate increase in 
the number of spherical bacteria can be demonstrated by the microscope. 
They are found in the discharge from the edges of the wound produced 
by tracheotomy, performed in the treatment of diphtheritic laryngitis, 
and upon these edges they multiply rapidly, just before a pseudo-mem- 
brane forms. If, upon any surface, which is the seat of ordinary catar- 
rhal inflammation, other vegetable organisms, as the leptothrix buccalis, 
or o'idium albicans, are present — if diphtheritic inflammation supervene, 
these organisms diminish and disappear, as if deprived of the required 
nutriment, and are succeeded by the sphero- and micro-bacteria, which 
increase in numbers as the specific inflammation extends. On the other 
hand, when the diphtheritic inflammation abates, these bacteria disap- 
pear, and other vegetable forms may succeed. In the very commence- 
ment of diphtheria, the grayish- white spots which appear upon the inflamed 
surface consist entirely of these bacteria, with epithelial cells and mucus, 
while fibrin and pus appear at a later period, as a result of inflammatory 
reaction. 

These facts having been ascertained, various experiments were made 
by Oertel, Hueter, Von Trendelenburg, Nasseloff, Eberth, and others, 
in order to determine more fully the exact relation of the sphero-bac- 
teria and micro-bacteria to diphtheria. These organisms were not found 
in the croupous membrane produced by the application of a powerful 
chemical agent, as ammonia, nor upon the inflamed surface underneath 
the membrane, " although the fibrous exudation afforded a soil which 
varied little or not at all in its histological and chemical composition 
from that induced by diphtheria." (Oertel.) The mucous membrane 
of the air-passages, the cornea and muscles in animals, were inoculated 
with diphtheritic matter, and these two kinds of bacteria were found to 
increase rapidly, penetrating tlie tissues in a short time, and infecting 
the system. Oertel says : " I have noticed in numerous inoculations 
that if various bacteria, besides the micrococcus, as, for instance, bacil- 
lus, spirillum, and bacterium lineola, were present in the matter to be 
inoculated, only micrococci (sphero-bacteria) and the bacterium termo 
(in its most minute forms accompanying them) showed evidence of pro- 
lific growth, while all other forms disappeared altogether." JNasseloff 
and Eberth inoculated the cornea with diphtheritic matter, and found 
that the sphero-bacteria and micro-bacteria penetrated its layers, forcing 
them apart, and causing within a few clays intense keratitis and the 
death of the animal by infection of the blood. "In the same way," 
says Oertel, " according to my experiments, the bacteria spread over 



300 DIPHTHERIA. 

the mucous membrane of the trachea, beset the cellular elements, crowd 
especially into the young exudation cells, or are taken up by them, and 
gradually cause their dissolution ; they fill the blood and lymph-vessels, 
and bring about, in a mechanical way, a damming-up of the fluids, and, 
as a consequence, serous exudation. As they close up the capillary 
vessels, they occasion stagnation in the blood circulation, which induces 
disturbance of nutrition in the walls of the capillaries, and even rup- 
ture of the same. Muscular fibres, also, which are covered and filled 
with colonies of micrococci, degenerate and slough ; in like manner, in 
severe cases, immense numbers of bacteria appear heaped up in the 
uriniferous tubules and Malpighian corpuscles of the kidneys, and occa- 
sion there parenchymatous inflammation, capillary embolism of the glo- 
meruli of the kidney, with ruptured vessels and formation of epithelial 
casts in the tubes. In the lymph and blood streams (compare also 
Hueter), in long-continued sickness of the animal experimented on, 
these bacteria also accumulate in masses. They induce, as exciters of 
decomposition and disorganization of organic nitrogenous bodies, septi- 
caemia, through the vegetative process they undergo, and through their 
relation to oxygen." 

Finally, Erfiirth repeatedly inoculated the cornea with a negative 
result, using for the purpose diphtheritic material from which the bac- 
teria had been so far as possible separated. 

The importance of such experiments cannot be too highly estimated. 
In the opinion of those who have performed them, the conclusion is 
certain that diphtheria is produced by bacteria, which, coming in 
contact with the mucous membrane, or the cuticle deprived of its epi- 
dermic covering, adhere to it ; and these, multiplying rapidly, burrow 
through the tissues, and entering the vessels, infect the whole system. 
The reason assigned why diphtheritic inflammation in most cases appears 
primarily and chiefly upon the faucial and nasal surfaces is, that the 
air, which contains the germs of the bacteria, constantly passes over 
these surfaces, and, as regards the fauces, the ingesta also, which may 
contain them. 

But the causes and nature of a disease cannot, in general, be fully 
elucidated by experiments alone, such as have been detailed. They 
should be aided or supplemented by clinical observations, and of these, 
as regards diphtheria, we have had an abundance in ' New York during 
the past fifteen years. Clinical observations may modify or correct the 
theories derived from the results of experiments. 

But, notwithstanding the many experiments and observations which 
have been made, the etiology of diphtheria, as Ziegler remarks, is still 
in doubt, though it is highly probable that its specific principle is the 
microorganism mentioned above, which " settles in the tissues " where 
the specific inflammation occurs, and thence " spreads through the 
system" (Ziegler). Wood and Formad, who in the employment of 
the State Board of Health made many experiments in 1882, arrived 
at the conclusion that micrococci are always present in diphtheria, but 
they express the opinion that they are the ordinary sluggish micrococci 
which are endued with " new power and virulence," and that they are 
the specific principle of diphtheria. 



NATURE — CAUSES. 301 

The question whether diphtheria is, in its inception, a local or a 
constitutional disease has been much discussed. If Ave accept the plausi- 
ble opinion that the virus gains admission into the system by lodgement 
upon one of the exposed surfaces, still clinical facts justify the belief 
that it quickly enters the system by the lymphatics or bloodvessels, so 
that the judicious physician will make use of constitutional measures 
from the commencement of his attendance. It is proper to state that 
Wood and Formad did not find micrococci in the blood in the mildest 
cases, but in cases of ordinary severity they were always present, so 
that, in their opinion, the mildest diphtheria may remain a local malady ; 
but it seems to me that the following facts justify the belief that, as it 
ordinarily occurs, diphtheria should be regarded and treated as a con- 
stitutional malady from the first visit of the physician. If the mildest 
cases remain local, still all such cases as involve danger are or quickly 
become constitutional : 

1. It is a law in pathology that those diseases which have or may 
have a long incubative period — say of a week or more — are constitu- 
tional. 

2. Another fact, which indicates primary blood-poisoning in diph- 
theria, is observed in certain cases, namely, the occurrence of severe 
constitutional symptoms for a longer or shorter time, perhaps for half 
a day, before the appearance of the usual inflammation. Thus a girl 
of five years, having malignant diphtheria, whom I saw in consultation, 
was carefully examined on the first day of her sickness by the attending 
physician, and, although he closely inspected the fauces, there was no 
appearance which indicated the nature of the malady till the subsequent 
day. In such cases, a sufficient number of which I have observed, 
there is apt to be complaint of soreness of the throat, or difficulty in 
swallowing, almost from the beginning of the general symptoms; but 
the pain and tenderness seem to be in the deeper tissues of the neck. 

Again, treatment of the inflammations by the most reliable and effi- 
cient antiseptics and disinfectants which we possess, commenced at the 
earliest possible moment and repeated at short intervals, does not pre- 
vent the occurrence of indubitable symptoms of blood-poisoning in cases 
of a severe type. Thus I have treated every portion of the inflamed 
surface, so far as it was accessible, every second or third hour, with 
carbolic acid and other disinfectants, almost from the very commence- 
ment of diphtheria, and so thoroughly that any vegetable or animal 
poison with which the remedies had come in contact would probably 
have been destroyed, or rendered inert, and yet, except in mild cases, 
symptoms of diphtheritic blood-poisoning have occurred, and as early 
and uniformly as if less energetic local measures had been employed. 
While, therefore, I do not fail to recommend local treatment as calculated 
to diminish septic poisoning, and relieve the inflammations, I have lost 
confidence in it as a means of preventing the entrance of the diphtheritic 
poison into the blood. Its powerlessness to prevent contamination of 
the blood by the diphtheritic virus is an additional evidence that this 
contamination occurs early. 

3. The quick succumbing of the system in certain malignant cases is 
evidently due to diphtheritic toxaemia. We sometimes observe a fatal 



302 DIPHTHERIA. 

result on the second, third, or fourth day, without any dyspnoea, or 
sufficient laryngitis to compromise life. Cases of this kind, terminating 
fatally even in the first day, have been reported. The system is suddenly 
overpowered by the poison, struck down, as it were, by the profound 
blood change, while the inflammations are still in their incipiency. 

4. Important evidence of the constitutional nature of diphtheria is 
afforded also by the state of the kidheys. No internal organs are so often 
affected in diphtheria as the kidneys, and on account of their location 
and anatomical relation, it is evident that the poison first passes through 
the system before it reaches them. Any clinical or anatomical fact, 
therefore, which indicates that the diphtheritic virus has reached and 
affected the kidneys, affords proof that it has penetrated the system, 
and poisoned the blood. Now the occurrence of albumen, with granular 
or hyaline casts, in the urine, in cases unattended by dyspnoea, affords 
proof of nephritis, caused by the action of the poison on the kidneys. 

Sir John Rose Cormack, of Paris, in a series of interesting and 
useful papers relating to diphtheria, published in the Edinburgh Medical 
Journal during 1876, states that albuminuria, and of course the 
nephritis on which it depends, sometimes begin as early as the first 
day. My observations confirm this statement, as in the following cases : 

Case 1. — L. McD., aged three years, was first visited by me on February 
29, 1876. I learned from the parents that she had been feverish during 
the preceding forty-eight hours, and her urine very scanty. A moment's 
examination was sufficient to show that the case was one of malignant 
diphtheria, for the fauces were already nearly covered by the diphtheritic 
pellicle, the temperature was 103j°, and the pulse 140. The skin was 
hot and dry, and there was moderate swelling under the ears, and a 
muco-purulent discharge from the nostrils. On account of the scantiness 
of the urine, the amount not exceeding f giv-v daily, it was impossible to 
obtain sufficient for examination till the following day. It was then 
found to have a specific gravity of 1032, to contain a deposit of urates 
and hyaline and granular casts, a diminished amount of urea, and a large 
quantity of albumen. It can hardly be doubted, from the scantiness of 
the urine, and the large amount of albumen found when the urine was 
first examined, that albuminuria had been present on the first day. 

Case 2. — The following was a similar case: K., aged four years, living 
in West Thirty-sixth Street, was visited by me in consultation on Jan. 
29, 1875. Her sickness had also continued forty-eight hours ; her fauces 
were swollen, and covered with the diphtheritic pellicle, which was dark 
and offensive; respiration guttural; pulse 120; temp. 101°; she had a 
free discharge from each nostril; urine scanty, its specific gravity 1030; 
it contained a small amount of albumen, with casts, and a large amount 
of urates, with no apparent diminution of the urea. Death occurred on 
the fourth day. 

In such severe cases, in which albumen and casts are found in the 
urine at the first visit of the physician, there can be little doubt that 
the nephritis begins nearly or quite as early as the pharyngitis, and 
therefore, since poisoning of the blood must antedate the renal disease, 
diphtheria affects the system very early, probably from the occurrence 
of the first symptoms. 



NATURE — CAUSES, 303 

Again there are cases, though not frequent — three I can recall to 
mind during the last two years in my practice — in which the external 
manifestations of diphtheria are very mild, even insignificant, and 
quickly cured, but in which the kidneys are early and severely affected. 
The occurrence of such cases is best explained on the supposition of 
an early and profound blood change. The following are histories of the 
cases alluded to : 

The house 229 West Nineteenth Street, New York, is an old wooden 
structure, and the family, which has occupied it during the last five years, 
has been three times visited by diphtheria, the first case, that of the oldest 
child, proving fatal. In February, 1876, one of the children had diph- 
theria in a moderately severe form. He recovered, and, after my visits 
had been discontinued, his sister, aged six years, who had had scarlet fever 
when eighteen months old, became feverish, and complained of her throat. 
No rash appeared on her skin, and there was apparently no coryza. In- 
spection of the fauces by the parents revealed a small diphtheritic patch 
over each tonsil. Although diphtheria was so frightful a malady to this 
family from their past experience, the case seemed so mild that the parents 
treated it without medical attendance, by the remedies which had been 
employed for the boy. A mixture of carbolic acid, subsulphate of iron, 
and glycerine, was applied to the fauces every third hour, sufficiently 
ofcen, apparently, to destroy all bacteria or other vegetable or animal 
organisms with which it might have come in contact, and within two or 
three days the inflammation of the throat seemed to the parents to be 
cured. Nevertheless, with this insignificant inflammation of the fauces, 
so quickly subdued, and with no other apparent inflammation of the 
mucous surfaces, there was severe internal disease going on as the result 
of the general infection. The child did not regain her former appetite ; 
she had increasing pallor, although able to play about the house : and, 
finally, in the third week, when I was called to see her, slight oedema of 
the face and limbs was observed. Her urine, which was scanty, was found 
to contain pus and blood corpuscles, albumen, and granular casts, and 
nearly two months elapsed before, under treatment, it became normal, 
and her health was restored. 

The second case occurred in January, 1878, in West Fifty-first Street. 
A boy, aged six years, in a family in which diphtheria was occurring, had 
slight sore throat, which abated in two or three days. It was attended by 
little or no exudation, and would not have been considered diphtheritic, 
except for the circumstances in which it occurred, and the subsequent 
history. Still, the boy remained ill, and fretful, and four days subse- 
quently his urine was found to be very scanty and very albuminous ; and 
three days later death occurred, preceded by total suppression of urine. 
The last urine passed, which was not more than a teaspoon ful, became 
nearly semi-solid by heat. There had been no scarlet fever in the family. 

Cases like the above, in which there is an early and profound systemic 
infection, with but slight evidence of lodgement of the virus upon the 
faucial or other exposed surface, are interesting as showing the consti- 
tutional nature of the malady, even when the symptoms and visible 
lesions have extreme mildness. 

Diphtheria, as experiments on animals and the histories of many 
reported cases show, is sometimes communicated by inoculation. Most 



30-i DIPHTHERIA. 

frequently, however, the virus is received from an infected atmosphere. 
The antihygienic conditions in which it originates are well known. 
Many cases in New York are traced to sewer gases, which have escaped 
into houses through imperfect plumbing. 

When diphtheria reappeared in New York in 1858, after an absence 
of more than fifty years, some of the first and most severe cases seen 
by myself occurred in the upper part of the city, along the old water- 
courses, where, in consequence of street grading, water was stagnant 
and impregnated with decaying animal and vegetable matter. Though 
observing and treating diphtheria, both in its epidemic and sporadic 
form, during the last twenty-five years, I have not observed an instance 
in which it seemed to be communicated from house to house by the 
clothing of a third person, as we frequently observe in cases of scarlet 
fever, and sometimes of measles. When it spreads from house to house, 
or even from room to room, in the same house, I think that it is almost 
always by the visits of persons having diphtheritic inflammation. The 
area of contagiousness of diphtheria is therefore limited to the room in 
which the patient resides, or to his immediate vicinity. 

But it is well known that the sputum of a diphtheritic patient and 
bits of diphtheritic pseudo-membrane may communicate diphtheria. 
Experiments indeed show this, as do many observations published in 
the records of diphtheria. Therefore, caution is required that children 
be not needlessly exposed to the handkerchiefs or towels employed by 
a patient, nor to his breath, especially during the act of coughing. 
We may here repeat that in localities where diphtheria is endemic or 
epidemic, certain constitutional diseases sustain a causative relation to 
diphtheria. Thus scarlet fever furnishes the conditions in which diph- 
theria arises in a house whose sanitary state is apparently good, and 
when there has apparently been no exposure to a diphtheritic patient. 
In three instances I have known diphtheria thus originating to become 
dissociated from scarlet fever, and spread as a primary and independent 
malady. 

Anatomical Characters. — In the commencement of diphtheria 
we observe redness of some portion of the mucous surface. In most 
cases it is the faucial membrane which is first affected, and that part of 
it which covers the tonsils. If there be a preexisting inflammation of 
one of the other mucous surfaces, or a portion of the cuticle denuded 
of its epidermis and inflamed, the specific inflammation is apt to appear 
primarily upon these parts, with or without its simultaneous appearance 
upon the faucial surface, a fact to which allusion has been made above. 

The inflammation varies greatly in severity and extent. In a mild 
attack it is often limited to a part of the fauces, and there are few 
exceptions to the rule that the tonsillar portion is affected, the redness 
gradually fading away in the healthy membrane beyond. In all except 
the mildest cases, the whole faucial surface is, in the course of a few 
hours, involved in the inflammatory process, its mucous membrane is 
thickened and softened, and its follicles tumefied, and actively secret- 
ing. In severe cases the uvula is elongated and enlarged from watery 
infiltration ; the submucous connective tissue also becomes involved to 
a greater or less extent, and swells ; and the submucous lymphatic 



ANATOMICAL CHARACTERS. 305 

glands, especially the tonsils, also swell, and are painful. The color 
of the inflamed surface is sometimes a deep, bright red, almost like 
arterial blood ; in other cases it is a dusky red, which indicates a viti- 
ated state of the blood. The dusky red hue is more common in second- 
ary than in primary diphtheria ; it is also common in the obstructive 
laryngitis of diphtheria, the color becoming more and more dusky as 
the obstruction increases. 

Within a day, and usually within a few hours, from the commence- 
ment of the inflammation, a small slightly raised patch or spot is ob- 
served, usually upon the tonsillar portion of the inflamed surface, of 
little importance, did the disease stop here, but very significant as a 
diagnostic sign, and as a forerunner of what is to happen. This patch, 
termed the pseudo-membrane, gradually becomes firmer, and at the 
same time thicker and broader from fresh exudations underneath, and 
it has a grayish or grayish- white color. Sometimes different points or 
patches are observed, which extend and coalesce so that the fauces are 
almost entirely concealed from view. The pseudo-membrane is closely 
attached to the mucous surface, which it penetrates, becoming firm, and 
not easily detached. Attempts to separate it often lacerate the engorged 
capillaries, producing a free flow of blood. It does not ordinarily attain 
a greater thickness than one-eighth to one-sixth of an inch. I have 
seen it, however, not far from one-third of an inch thick. By the 
microscope we observe numerous micrococci with a small number of 
rod-like bacteria in the meshes of the exudation. They can be traced 
through the subepithelial tissues, being adherent to and even incorpo- 
rated in pus-cells, and entering into and blocking up the minute lym- 
phatics and bloodvessels. 

The same pseudo-membrane is often firmer in one part than another, 
the outer and central portions being more compact and tough for a time 
than that underneath, which is more recent, and in which there is less 
fibrillation. After a few days, however, decomposition commences, and 
then that which was first formed becomes softer than the more recent 
production. When this occurs, the color of the exudation changes from 
a whitish or a grayish-white to a dirty brown, and its exposed surface is 
uneven and jagged from the partial separation of shreds and fibres. 

The escape of the liquor sanguinis from the engorged vessels dimin- 
ishes somewhat the turgescence of the inflamed tissue. If this be con- 
siderable, the pseudo-membrane often sinks to the level of the surround- 
ing surface, producing an appearance very much like that of an ulcer, 
or even of gangrene. Though there is no loss of substance in this stage 
of the pseudo-membrane, it does, however, often occur, being produced 
by the presence and contraction of the fibrin with which the mucous 
membrane is infiltrated. Sometimes the pseudo-membrane has a red- 
dish tinge. This is due to rupture of the capillaries, and the escape of 
the blood-corpuscles. It occurs in those cases in which the inflamma- 
tion is intense, and the capillaries are greatly engorged. Sometimes 
the lower part of the exudation is blood-stained, while the exposed sur- 
face has the usual grayish-white hue. 

Briefly stated, the exudation of diphtheria is found to consist of 
fibrin forming a delicate interlacing network, epithelial cells more or 

20 



306 DIPHTHERIA. 

less altered by the inflammatory process, leucocytes, nuclei, mucus, and 
amorphous matter. Upon the faucial, buccal, laryngeal, and perhaps 
also nasal surfaces, the pseudo-membrane penetrates the entire mucous 
membrane, so that no line of demarcation between them can be seen 
with the microscope. Below the larynx upon the surface of the trachea 
and bronchial tubes, a distinct line of demarcation exists, as in the 
croupous exudation, so that the tracheal and bronchial pseudo-membrane 
can be readily detached, without impairing the integrity of the under- 
lying mucous surface. 

The inflamed mucous membrane is not only hyperaemic and infil- 
trated with serum, but it contains numerous round white corpuscles 
(leucocytes), which may result in part from proliferation of connective 
tissue corpuscles, but are believed by most pathologists, since Cohn- 
heim's well-known discovery, to be in great part wandering white cor- 
puscles of the blood, which have escaped through the walls of the 
bloodvessels along with the fibrin. In the commencement of the diph- 
theritic inflammation, before the pseudo-membrane forms, we often 
observe a grayish tinge of the mucous surface, which is due to the 
crowding of these cellular elements underneath and in the mucous 
membrane, for these newly formed cells can be traced into the sub- 
mucous connective tissue. Even where the inflammation remains 
catarrhal, as it does over certain areas in all cases of diphtheria, this 
infiltration of the mucous and submucous tissues with cells is common. 

During the height of the inflammation, it is astonishing often to see 
with what rapidity the pseudo-membrane returns, when removed by 
force. A few hours suffice to restore it as firm and extensive as before 
the interference. In favorable cases this adventitious layer is detached 
in a few days, and is either expectorated or swallowed with the ingesta. 
Its separation is promoted by the secretions underneath, especially by 
pus, which is formed in abundance between it and the surface on which, 
and in which it lies. In most cases it does not separate in mass, but 
disappears, by progressive liquefaction, a little less remaining at each 
visit till all is detached. 

Such are the appearances, character, and history of the pseudo-mem- 
brane in this malady. Although its common seat is upon the fauces, 
and in mild cases it occurs only upon the fauces, nevertheless all the 
mucous surfaces are liable to be attacked by the inflammation, in conse- 
quence of infection of the blood, and therefore in severe cases, and even 
in cases of moderate severity, we often find the product elsewhere, as 
well as upon the fauces, and in localities where from its mechanical 
effect it greatly increases the danger and even compromises life. The 
mucous membrane of the nostrils, mouth, larynx, trachea, bronchial 
tubes, oesophagus, stomach, intestines, conjunctiva, vagina, and even the 
delicate lining of the middle ear, are at times the seat of diphtheritic 
inflammation, with the characteristic product. In a case which oc- 
curred in the Nursery and Child's Hospital of New York, the surface 
of the stomach was almost completely lined with the diphtheritic forma- 
tion, so that the function of this organ was apparently nearly or quite 
abolished. The occurrence of the pseudo-membrane in the nares is 
common, and is attended by the discharge of thin mucus and pus, but 



ANATOMICAL CHARACTERS 307 

though inconvenient to the patient, its mechanical effect is not dan- 
gerous, except in the nursing infant, in whom it interferes, more or 
less, with lactation, The thin irritating discharge produces excoriation 
around the nostrils, and upon the upper lip. I have met only one case 
of diphtheritic inflammation of the intestines, in which the diagnosis 
was certain. A physician, in whose family severe diphtheria had just 
occurred, took what was believed to be typhoid fever. After a long 
sickness, he expelled, per rectum, about one foot of diphtheritic pseudo- 
membrane in a cylindrical form, evidently produced upon the intestinal 
walls. In the subsequent months the patient suffered from constipation, 
and severe abdominal pains, apparently due to contraction in healing 
of the large diphtheritic intestinal ulcer. Death finally occurred from 
this state of the intestines. The formation of the diphtheritic pellicle 
upon the vulva and vaginal walls is occasionally observed, as in one of 
the cases related above. Its occurrence upon the uterine surface is 
very rare, except in the parturient woman, in whom it is said to occur 
by preference upon that part from which the placenta has been detached. 

In mild cases of diphtheria, in which the pseudo-membrane is small, 
and quite superficial, penetrating but little the mucous membrane, in 
which it is embedded, there is little danger of septic poisoning. But in 
grave cases, in which the diphtheritic pellicle is extensive, and deeply 
embedded, so that the lymphatic and bloodvessels are in immediate 
relation with its under surface, the conditions in which septicaemia 
occurs are present as soon as decomposition begins. Therefore septi- 
caemia is properly regarded as a not infrequent and dangerous accident 
in severe diphtheria, but it is" obviously very difficult to distinguish 
septic from diphtheritic blood poisoning, from the symptoms. Septi- 
caemia is most apt to occur in those cases in which pseudo-membrane 
has become dark gray, and friable, from decomposition, producing an 
ichorous discharge and offensive breath, and in cases in which blood 
escapes from the capillaries underneath. 

Absorption of the poisonous substance produces inflammation of the 
lymphatic vessels, along which it passes, and of the lymphatic glands, 
which these vessels enter. The adenitis also gives rise to inflammation 
of the periglandular connective tissue, so that the neck is thickened, 
hard, and tender. If we examine a gland which is swollen and inflamed 
by the toxic absorption, we will find that its bloodvessels are congested, 
and its cells have undergone hyperplasia. The periglandular connective 
tissue is oedematous, and sometimes infiltrated with lymphoid cell-nuclei 
and pus-corpuscles. * Capillary hemorrhages are also common in the 
connective tissue, and micrococci are found in the lymphatic vessels, 
lymphatic glands, and in the connective tissue. 

If death occur from obstruction in the air-passages, the lungs will be 
found much reduced in size, the anterior superior portions being pale 
from lack of blood, and perhaps emphysematous, while the posterior 
and inferior portions have a dark red color, many of the lobules being 
collapsed, and others not only collapsed or semi-collapsed, but in the 
commencement of pneumonia. This difference in the state of different 
parts of the lungs, in those who have died of suffocation in consequence 
of the presence of the false membrane in the air-passages, receives 



308 DIPHTHERIA. 

partial explanation from the seat of the exudation in the bronchial 
tubes, for in those who perish from this cause the exudation is found 
chiefly in such tubes as pass to posterior and inferior parts of the organ, 
while such as pass to the superior and anterior lobules remain free from 
it. In some instances, in parts of the lungs the pseudo-membrane can 
be traced along the minute bronchial tubes into the alveoli, where it 
forms a network — containing in its interstices pus, and sometimes blood- 
corpuscles, and more or fewer micrococci. Pneumonia is also a common 
complication, resulting from downward extension of the bronchitis, or 
occurring independently of the bronchitis. 

The muscular fibres of the heart in diphtheria, as in all acute infec- 
tious diseases, are liable to granulo-fatty degeneration, so that they 
become softer, and have a color which French writers liken to that of new 
leather or coffee and milk. This degeneration has been observed only 
in a certain proportion of the more malignant cases, and is far from 
being uniform. Any portion of the heart may undergo this change. 
It may occur in the columns carnese, or in the walls of the organ. 
White fibrinous ante-mortem clots are sometimes seen in the cavities of 
the heart after death from diphtheria. 

The blood in cases of a severe type is usually darker than in health, 
and the clots soft. After death from diphtheritic laryngitis, it is also 
dark from excess of carbonic acid in it. The chemical changes which 
the blood undergoes in diphtheria are little known. MM. Andral and 
Gavarret found a notable diminution of fibrin in grave infectious dis- 
eases, as typhoid fever, puerperal fever, etc., and it is not improbable 
that the same is true of diphtheritic blood, although the exudation of 
fibrin is so abundant. M. Bouchut and others have found a marked 
excess of the white corpuscles in the blood in a considerable proportion 
of diphtheritic patients, so that, instead of three or four in the field of 
the microscope, as many as sixty have been counted. M. Sanne writes 
of diphtheria, " It is necessary to recognize in the dark brown blood an 
abnormal accumulation of the debris of the red corpuscles, debris of 
little abundance in the normal state, augmented considerably under the 
noxious influence of the diphtheritic poison, which has rapidly pro- 
duced destruction of a great number of globules" (Traite cle la Diph- 
theric, page 107, Paris, 1877). Small extravasations of blood in various 
organs are among the most constant lesions. They have been most fre- 
quently observed in the brain and its meninges, the lungs, spleen, and 
kidneys. In one of the cases which I examined after death in the New 
York Foundling Asylum, the extravasations in and under the gastric 
mucous membrane produced mottling as great as that of the skin in 
measles. The micrococci enter the white corpuscles, and no doubt 
exert a deleterious effect on their function and vitality. 

No notable changes have thus far been observed in the nervous centres, 
with the exception of the apoplectic foci, and softening of adjacent brain 
substance, and the congestion present when death has resulted from 
diphtheritic croup. But certain degenerative changes have been dis- 
covered in the peripheral nerves, as well as in the muscles in parts 
affected with diphtheritic paralysis. Thus, in nerves from a paralyzed 
palate, certain nerve tubes have been observed nearly or quite destitute 



SYMPTOMS. 309 

of medullary matter, though this is not common, but many tubes are 
found to contain fatty granules, the result of retrogressive metamor- 
phosis (MM. Charcot and Vulpian). 

The liver does not appear to be seriously engaged or its function com- 
promised. In most acute infectious diseases which are fatal in conse- 
quence of blood poisoning, the spleen is apt to become softened and 
somewhat enlarged, but this does not always occur in diphtheria. It 
will be recollected from the cases related above that the spleen may not 
be perceptibly enlarged or softened. 

The kidneys of all the internal organs are most frequently affected, 
as is shown by the common occurrence of albuminuria. Parenchy- 
matous nephritis, with the characteristic hyperaemia and swelling, is the 
usual form of kidney disease which complicates diphtheria. In the albu- 
minous urine are found hyaline and granular casts. This inflammation 
may begin early in grave cases, even as soon as the first or second day, 
but its commencement is ordinarily not till toward the close of the first 
week or in the second. It occurs in the majority of those severe cases 
which prove fatal from blood poisoning. Interstitial nephritis has also 
been not infrequently observed in parts of the kidney. 

Symptoms. — In general, in the commencement of an epidemic, diph- 
theria is more severe and fatal than when the epidemic influence is 
abating. The prominent symptoms, such as arrest the attention of the 
friends, are often disproportionate to the gravity of the attack. Strik- 
ing cases illustrative of this have occurred in my practice, the friends 
not supposing that there was any serious ailment, and not seeking 
medical advice till the fatal termination had nearly arrived. The 
initial symptoms are sometimes mild, such as chilliness or rigors, often 
slight, and succeeded by moderate febrile reaction, languor, and perhaps 
more or less headache, pain in the limbs or back, and impaired appetite. 
Still the patient may continue to walk about as if affected with slight 
and temporary ailment. Children thus affected frequently attend the 
schools, and do immense harm in propagating the disease. The symp- 
toms in these mild cases are often like those from a cold, for which light 
attacks of diphtheria are apt to be mistaken by the friends. With 
some, in mild as well as severe diphtheria, one of the first symptoms is 
slight tenderness or a sensation of fulness in the fauces. A distin- 
guished clergyman of the Pacific coast, who fell a victim to this disease, 
dreamed, a few nights before he complained of illness, that his throat 
was cut. Doubtless the diphtheritic inflammation had already com- 
menced, so that what seemed a forewarning had a natural explanation. 
So insidious was the commencement in this case that the disease had 
advanced beyond all hope of relief when medical advice was first sought. 
But in most cases, other than those of a very mild type, the commence- 
ment is more severe, being attended by a temperature of 102° or 103°, 
or even 104°, with corresponding heat of surface, thirst, languor, loss 
or impairment of appetite, tenderness of throat, etc. Delirium ' as well 
as eclampsia may occur, but both are rare. The febrile reaction ordi- 
narily abates considerably by the close of the second or on the third 
day, as I have noticed in many observations. 

The symptoms of invasion have less prognostic value in diphtheria 



310 DIPHTHERIA. 

than in most other infectious maladies. We meet cases with a severe 
beginning, attended by delirium, which terminate in apparently com- 
plete restoration to health in less than a week, the presence of the 
characteristic pellicle upon the fauces and the occurrence of diphtheria 
in other members of the family rendering the diagnosis certain. On 
the other hand, a mild commencement sometimes ushers in a fatal form 
of the disease. This is notably true of those cases in which laryngitis 
supervenes, as it not infrequently does in cases which begin very mildly. 

The fever which ushers in diphtheria usually begins to abate after 
the second or third day, and subsequently, in grave as well as in benign 
cases, there may be but little or even no elevation of temperature. The 
diphtheritic poison does not, therefore, like that of scarlet fever, exhibit 
any marked tendency to increase the animal heat. Even in profound 
and fatal blood poisoning in this disease, the thermometer shows the 
normal, or scarcely more than normal, temperature, so that the inex- 
perienced practitioner may be deceived in his prognosis. On the other 
hand, a continued elevation of temperature with only moderate angina 
should lead the physician to examine for some complication, perhaps 
nephritis. 

The tongue is moist, and slightly furred. The patient often vomits 
in the commencement, and if this symptom cease or be seldom repeated, 
it is not grave ; but vomiting occurring often, so that the food is re- 
jected, and due as it frequently is to uraemia, is not uncommon in 
severe cases. The appetite varies. Repugnance to food characterizes 
many of the gravest cases, and, if the child be compelled to take it, it 
is often rejected by vomiting. There are no notable symptoms refer- 
able to the state of the intestines. The stools usually appear normal, 
except as they are changed by medicines. 

The respiratory apparatus is not involved in benign cases in which 
only the fauces are inflamed. But next to the fauces and posterior 
buccal surface, the Schneiderian membrane is most frequently affected 
of all the surfaces, and when the nares are inflamed, and are covered 
to a greater or less extent by the j:>seudo-membrane, there is more or 
less discharge, which may excoriate the upper lip, and cause incrustation 
around the entrance of the nostrils. This often renders respiration 
through the nostrils difficult. In cases having this severity there is 
usually at the same time considerable faucial swelling, so as to cause 
guttural respiration, which is most marked in sleep. But the most 
important symptoms pertaining to the respiratory apparatus, occur when 
the inflammation attacks the laryngeal or laryngeal and tracheal surfaces, 
constituting diphtheritic croup. 

Diphtheritic croup often occurs at the commencement of diphtheria, 
so as to be and continue to be the predominant inflammation, but in 
other cases it supervenes after diphtheria has continued a few clays. 
There are many mild cases, which give no anxiety so long as the inflam- 
mation remains faucial, but in which the whole aspect is within a day 
changed by the occurrence of croup, and the condition becomes one of 
imminent danger. Usually when diphtheritic croup occurs there is a 
simultaneous if not preexisting exudation upon the fauces. Occasion- 
ally in undoubted diphtheria the diphtheritic pellicle forms only upon 



SYMPTOMS. 311 

the surface of the air-passages below the epiglottis, while the fauces 
present merely an inflammatory reddening, and the surface of the nares 
is either free from disease or only reddened. The reader is referred to 
the chapter relating to diphtheritic croup. 

In New York, as will be seen by the table below, the predominant 
inflammation in about one-fourth of the cases of diphtheria is the laryn- 
gitis. 

In addition to the accelerated pulse during the febrile stage and the 
slow and compressible pulse during the stage of profound blood poison- 
ing, the chief symptoms, pertaining to the circulatory system, relate to 
the state of the heart, and the altered state of the blood which gives 
rise to hemorrhages. The ante-mortem heart-clots, the weakened 
action of the heart from degenerated muscular fibres, the hemorrhages 
from the altered state of the blood, indicate a very dangerous condition 
of the circulatory apparatus. 

Very little attention had been bestowed upon the state of the kidneys, 
and the character of the urine in diphtheria, till Mr. Wade, of Birming- 
ham, discovered albuminuria, since which many observations in different 
epidemics, and localities, have established the fact that albuminuria 
occurs in a majority of cases of a severe type, and in many cases of 
diphtheritic laryngitis in which the type is not severe. Two conditions 
of the kidneys give rise to albuminous urine, namely, nephritis, which 
is the most common, and venous congestion, which occurs in cases of 
embarrassed circulation, as in certain cases of diphtheritic laryngitis, 
and in obstruction from heart clots. The latter is comparatively infre- 
quent. 

During the latter part of 1875, and in 1876, prior to August 1, I 
endeavored to obtain and examine the urine in every case of idiopathic 
diphtheria, having a clear diagnosis, which came under my notice, both 
in family practice and in institutions with which I have an official con- 
nection. Ordinarily, during the first week of a case, I found that the 
urine deposited urates on cooling, and that the nitric acid test showed a 
large relative quantity of urea, but I suspect that this was due to a 
somewhat diminished quantity of urine. But the occurrence of albumen 
was of chief interest, and the results of the examinations as regards the 
presence or absence of this, are recorded in the accompanying table. 
In most cases the urine was examined several times in the course of the 
disease, and, if albumen was present, a microscopic examination was 
also made. In nearly all the specimens which contained albumen — all 
but three or four — casts, usually granular, but now and then hyaline, 
and sometimes both kinds in the same specimens, were observed. In 
those cases of albuminuria which recovered, there were comparatively 
few casts, or none. If the albumen was abundant, and casts plentiful, 
the case was usually fatal, though not perhaps till after the lapse of three 
or four weeks, when death occurred with symptoms of exhaustion, 
paralysis, or feeble heart-action, sometimes with oedema of lungs super- 
vening suddenly, and, probably, formation of heart clots. The albumin- 
uria, unlike that of scarlet fever, seldom occurred except in the grave 
cases ; and in the majority of instances it did not appear till near the 
close of the first week, or in the second, and, in a few instances, not till 



312 DIPHTHERIA. 

a later period. Although the albuminuria of diphtheria is much more 
grave than that of scarlet fever, it has in my practice been attended by 
much less serous effusion or dropsy, often by none which was appreci- 
able. The urine, although containing a large quantity of albumen, 
ordinarily had nearly the normal appearance, instead of the smoky or 
hazy color so common in the albuminous urine of scarlet fever. 

I. Cases attended with the usual membranous exudation upon the fauces, with or 
without coryza, and without laryngitis or with only catarrhal laryngitis ; fifty - 
eight cases. 





Died. 


Recovered. 


Result not 
stated. 


Total 


"With albuminuria 
Without albuminuria . 
State of urine not recorded 


. 13 

. 4 

3 


5 

27 
4 


1 
1 


19 

32 

7 



II. Cases attended with membranous laryngitis as the predominant inflammation; 

nineteen cases. 

Died. Recovered. Total. 

With albuminuria .... 4 1 5 

Without albuminuria ... 2 4 6 

State of urine not recorded ... 7 1 8 

The mortality of the cases embraced in the above table was probably 
larger than the average in New York practice, for several of them were 
seen in consultation, and their type was severe. Those in which the 
state of the urine could not be ascertained, were usually children so 
young or so near death that it was impossible to obtain sufficient urine 
for examination. 

It is seen that in New York, where diphtheria is endemic, of 62 cases 
occurring in the course of about ten months, 21 were attended by albu- 
minuria, and 38 were exempt. In a larger number of cases, of which I 
have preserved the records since 1876, I think that the proportion of 
albuminous cases has been about the same, but obviously during epi- 
demics of a severe type the proportion is larger than when the type is 
mild. 

An efflorescence is sometimes observed upon the skin during the time 
in which the temperature is exalted. It is the erythema iugax of der- 
matologists, suddenly appearing and disappearing. This eruption, which 
is so common in the febrile and inflammatory affections of childhood, 
does not seem to present any peculiar characters in children. But there 
is another eruption, which I have several times observed, and of which 
I have preserved a drawing as it appeared in one case, which I have no 
doubt is due to diphtheritic toxaemia, or to septicaemia occurring in diph- 
theria. It appears after the sixth or seventh day, in the form of red 
points or spots, not more than a line in diameter, and interspersed with 
patches of larger size, and irregular margins, one to two inches in diam- 
eter. This roseolar eruption is slightly raised, like that of measles; 
it disappears on pressure, and, in my practice, has appeared usually in 
fatal cases. Occasionally extravasations of blood occur in and under 
the skin, like those in the internal organs. The pallor of the skin 
which diphtheritic toxaemia produces in the second and third weeks, 
is known to all who have had experience with this disease. 



SYMPTOMS. 313 

Diphtheritic paralysis is described by some writers as a symptom and 
by others as a sequel. It usually begins during convalescence in the 
second or third week after the abatement of the inflammatory symptoms, 
but sometimes not till a later stage. It may on the other hand appear 
considerably earlier, during the development of the inflammations, as 
early as the fifth or sixth day, or even as early as the second or third 
day from the beginning of the diphtheria (Sanne). When the paral- 
ysis begins at an early period it may cease, and reappear later, and 
in other parts. Its commencement may not be announced by any 
symptoms apart from the loss of muscular power, but in other cases 
there is febrile movement with albuminuria. The muscles most fre- 
quently affected are those of the pharynx, and upper part of the larynx. 
The muscles of deglutition are sometimes so involved, that the food and 
drinks are not swallowed till after several successive efforts, and a part 
may be returned through the nostrils. A portion of the food some- 
times enters the larynx, so as to produce violent coughing. As we 
observe the dysphagia, it seems as if there must be pharyngitis, which 
renders deglutition difficult, but on inspecting the fauces we find no 
evidence of inflammation. The mucous membrane ordinarily appears 
normal, and the nerves only are affected. The velum palati hangs 
flaccid and motionless like a curtain ; and the relaxed state of the 
muscles at the entrance of the larynx causes guttural respiration, 
or snoring in certain cases, which is especially marked during sleep. 
In severe cases the difficulty of swallowing may endanger suffocation 
from the lodgement of food in the larynx, and inspire dread of taking 
food on the part of the child. Tickling, and even pricking the velum 
fails to induce motion. In some there is only faucial paralysis, but in 
many the loss of muscular power occurs in other parts also. Whenever 
it occurs elsewhere, the pharyngeal muscles are also usually involved 
at the same time. Diphtheritic paralysis may affect the motor muscles 
of the eye, causing strabismus ; the muscles of one side, causing hemi- 
plegia ; of the legs, causing paraplegia ; or of an arm on one side and 
leg on the opposite. It does not commence simultaneously in the 
various muscles which are affected, but in succession, those first affected 
being for the most part the muscles of the pharynx. In some patients 
the muscles of the bladder are paralyzed, leading to retention of urine 
or difficulty in passing it. Paralysis in the limbs is frequently pre- 
ceded by tingling or a sensation of formication. There is often not a 
total loss of sensation or of motion in the paralyzed part, but more or 
less numbness with difficulty rather than impossibility of motion. A 
few cases have been reported in which the paralysis was almost general, 
and some believe that they have met cases in which the heart was 
paralyzed, death occurring suddenly and unexpectedly. Dr. J. B. 
Reynolds relates a case in the New York Journal of Medicine, May, 
1860, in which there were not only strabismus, partial paralysis of the 
limbs, and paralysis of the muscles of the pharynx, so that food was 
regurgitated, but the head dropped forward so that the chin rested on 
the sternum. 

A majority of those affected with paralysis recover, although few 
regain complete use of their muscles in less than one month, and many 
do not till between two and four months. 



314: DIPHTHERIA. 

Defect of vision is an occasional result of diphtheria; some have 
presbyopia ; others myopia ; some see double ; some are amaurotic ; 
while in others one pupil is more dilated than the other, or both pupils 
are dilated, and feebly sensitive to light. The impairment or perver- 
sion of vision gradually disappears as the vigor of system returns. 

Various theories have been advanced in explanation of the occur- 
rence of the paralysis, as that of reflex irritation advocated by Brown- 
Sequard, that of anaemia, etc. A careful examination of the nervous 
centres, made in certain fatal cases, has revealed nothing which throws 
light on its etiology. That the diphtheritic virus causes paralysis by 
some special action is evident, for there is no other infectious disease 
which is attended and followed by paralysis so often as diphtheria. 
The most plausible theory is that recently brought to light by histo- 
logical examinations, which have shown that the peripheral nerves in 
paralyzed parts have undergone degenerative changes, as mentioned 
above, so that under the neurilemma, we observe more or less granular 
matter, in place of the normal nerve tissue, or lying in this tissue. 
Among the many anatomical changes which the specific principle pro- 
duces, those in the peripheral nerves must therefore be regarded as 
important, since pathological changes in the nerves which supply 
paralyzed muscles sanction the belief that they sustain a causative 
relation to the paralysis. 

Diagnosis. — In most instances the diagnosis of diphtheria is readily 
made when the case has continued a few hours, for the characteristic 
false membrane is observed on inspection of the fauces. The physician 
is usually at his first visit able to state the nature of the pharyngitis from 
its appearance. But there are cases which vary from the typical form 
in which the diagnosis is more or less difficult. The confervoid growth 
of sprue, when occurring upon the fauces, is sometimes mistaken for 
the false membrane of diphtheria, but the error of mistaking one for 
the other in cases which I have met, has been due to hasty and careless 
examination rather than to any real difficulty in the discrimination. 
The peculiar product of sprue has but little depth and coherence, and 
is readily detached without injury to the mucous membrane or its 
vessels. If there be any doubt, the differential diagnosis can be readily 
made by the microscope. 

Follicular pharyngitis, like diphtheria, commences with sharp fever, 
which, however, is ephemeral, and is attended with the formation of 
round white masses in the site of the follicles, usually over the tonsils 
only. These masses do not occur in patches, like those of diphtheria, 
except when two or three are in close proximity and unite, but at the 
same time a sufficient number are discrete to establish the diagnosis. 
Follicular pharyngitis often occurs in several members of a family at 
the same time, involves no danger, and is quickly cured. The white 
masses consist of the inspissated secretion of the follicles mixed with 
epithelial cells. 

Prognosis. — No infectious disease presents greater difference in 
type or severity. In mild epidemics, with moderate fever, slight 
faucial swelling, and little extent of the pseudo-membrane, a large 
majority recover, and would recover even without treatment. Uncer- 



PROGNOSIS. 315 

tainty of prognosis, of which even physicians of ample experience com- 
plain, is largely due to the fact that diphtheria terminates fatally in 
several distinct ways. Hence while the patient may be secure as 
regards the more manifest and common conditions of danger, so as to 
justify a favorable prognosis in the opinion of the physician who attends 
him, the fatal result may suddenly occur from some unseen and unsus- 
pected cause. # 

Death in diphtheria may result from— 

1st. Diphtheritic blood-poisoning. 

2d. Probably, also, from septic blood-poisoning produced by absorp- 
tion from the under surface of the decomposing pseudo-membrane. But 
it is difficult to distinguish the constitutional effects of sepsis from those 
produced by the diphtheritic poison. Septic poisoning is obviously 
most apt to occur in those cases in which the pseudo-membrane is ex- 
tensive, and deeply embedded, and its decomposition attended by an 
offensive effluvium. Cervical cellulitis, and adenitis, which, when 
severe, cause very considerable swelling of the neck, appear to be often, 
if not usually, due to septic absorption from the faucial surface, the in- 
flammation extending from the absorbents to the glands and connective 
tissue. Considerable tumefaction of the neck, therefore, seldom occurs 
in diphtheria or scarlet fever, without manifest symptoms of toxaemia, 
and it is to be regarded as a sign of its presence. 

3d. Obstructive laryngitis. 

4th. Uraemia. 

5th. Sudden failure of the heart's action, either from the anaemia, 
and general feebleness, from granulo-fatty degeneration of the muscular 
fibres of the heart, which is liable to occur in all infectious diseases of a 
malignant type, or from ante-mortem heart clots. 

6th. Suddenly developed passive congestion and oedema of the 
lungs, probably due to feebleness of the heart's action, or to paralysis 
of the respiratory muscles. I have known death to occur apparently 
from this cause during the period of supposed convalescence, and when 
the visits of the physician had been discontinued. Thus in a case in 
my practice, symptoms of oedema pulmonum (moist rales in both sides 
of the chest, and embarrassed breathing) suddenly occurred nearly one 
month after the disappearance of the faucial pseudo-membrane and in- 
flammation. The urine, which had contained considerable albumen 
during the active period of the malady, had for some time shown no 
trace, or but slight trace, of this principle by the proper tests. By 
active stimulation these symptoms entirely disappeared in a few hours, 
and the heart's action seemed normal, unless a little weakened. On 
the "following day the same symptoms reappeared, and death occurred 
before I was able to reach the house. 

That physician obviously is least apt to err in prognosis, who recog- 
nizes the fact that patients are liable to perish in any of these different 
ways, and carefully examines in reference to all the conditions which 
involve danger. Many physicians, as I have had the opportunity to 
observe, are remiss in not examining more frequently the urine of diph- 
theritic patients, for there is often a large amount of albumen in the 



316 DIPHTHERIA. 

urine in diphtheria, indicating a poisonous quantity of urea in the blood, 
and yet the appearance of the urine to the naked eye is probably normal. 

Among the symptoms which render the prognosis unfavorable are, 
repugnance to food, vomiting, pallor of countenance, with progressive 
weakness and emaciation from the blood-poisoning ; a large amount of 
albumen with casts in the urine, showing urgemia, to which the vomiting 
is sometimes, but not always, attributable ; a free discharge from the 
nostrils, or occlusion of them by inflammatory thickening, and exuda- 
tion, showing that a considerable portion of the Schneiderian membrane 
is involved, hemorrhage from the nostrils or fauces, and obstructed res- 
piration. In diphtheritic laryngitis, attended by obstructed respiration, 
a large majority have thus far died, whether treated by the most approved 
inhalations or by tracheotomy. One, at least, of the above symptoms 
has been present in most of the fatal cases which I have observed. 

Treatment. — Although diphtheria has been one of the most common 
of the severe infectious maladies in this country during the last twenty- 
five years, physicians are far from agreeing in reference to the proper 
mode of treatment. This difference of opinion respecting the therapeutic 
requirements is due in part to difference in the type of the malady in 
different localities and epidemics, in part to difference in diagnosis, so 
that one considers a case to be diphtheritic, which another regards as a 
non-specific inflammation, but more to the fact that different theories are 
held respecting the cause and nature of diphtheria. Scarcely any other 
disease presents such a diversity in type as diphtheria, from cases so 
mild that nearly all recover, whatever the measures employed, to those 
so severe that a large proportion die under the best possible treatment ; 
and this difference in type may be observed in cases occurring at the 
same time in a great city like New York, and even in the cases which 
two physicians practising near each other may be called to treat. Hence 
one physician recommends with confidence a medicine or mode of treat- 
ment as eminently successful in his hands, of which another speaks dis- 
paragingly. 

The germ theory, which has been described above, according to which 
diphtheria is produced by microorganisms, has had a marked influence on 
the therapeutics of this malady. Acceptance of the germ theory does 
not require us to believe that diphtheria is primarily local, for these 
organisms might enter and infect the blood through' the lungs, before 
any symptom occurred, but as it is ordinarily promulgated, we are taught 
that these organisms alight upon one of the exposed surfaces, usually the 
fauces, where they excite local inflammatory action, and if not promptly 
destroyed they soon penetrate the tissues, enter the blood, and estab- 
lish a constitutional disease. Acceptance of this theory evidently leads 
to the employment of germicide medicines, the so-called antiseptics, 
or anti-ferments, externally and internally, to arrest and destroy the 
vegetable growth, their local use sufficing, according to the theory, in 
the early stage, when these organisms have passed no further than the 
surface, but their internal use being required in addition, if the malady 
has continued longer, and. the disease become general. Hence, in pro- 
portion as this doctrine came in vogue, carbolic acid, chlorine prepara- 
tions, bromine, the sulphites, phenic acid, and, as the best representative 



TREATMENT. 317 

of this class of medicines, and most powerful antiseptic, salicylic acid, 
attained at once prominence as the agents which would be most likely 
to cure diphtheria, by destroying the cause. A solution of bromine and 
bromide of potassium having been used with apparent good results in 
the antiseptic surgery of the army during the late war, has obtained 
under the influence of this theory some reputation in New York as a 
remedy for diphtheria, employed externally and internally, and without 
the aid of other therapeutic agents. A certain number of drops are 
administered internally every hour, or second hour, properly diluted, 
and the same medicine undiluted, or with less dilution, is applied to the 
fauces with a brush at regular intervals. 

But experience, if sufficiently extensive, is the safe guide in thera- 
peutics, and internal antiseptic measures have not seemed, so far as 
my observations extend, to exert any marked controlling effect on the 
course of diphtheria. 

Thus, a child of four years, whose case I was able to follow, took, almost 
from the beginning of the sickness, a mixture of potassa and iron on the 
first hour, two grains of quinine on the second hour, and three grains of 
salicylic acid on the third hour, and this treatment was continued night 
and day ; and yet this child, having from the first taken sixteen grains 
of quinine, twenty-four of salicylic acid, besides the potash and iron 
daily, died after eight days with profound blood poisoning, having had 
many extravasations of blood. 

This case, which presented the ordinary history of fatal diphtheria, 
did not seem to be materially modified by the internal antiseptic treat- 
ment. It would apparently have clone as well without it. It is but one 
case, though an average example, and I have not observed any other in 
which the internal use of antiseptics seemed to produce a curative effect. 
My knowledge, however, of the bromine treatment is limited to the four 
children of one family, and to the effects of its use, which have been 
reported to me by others. 

Between December, 1875, and July, 1878, 1 examined minutely, and 
preserved records of, 104 cases of primary diphtheria, occurring either 
in my private practice, or seen by me in consultation, besides observing 
cases, and witnessing autopsies in the New York Foundling Asylum, 
where diphtheria was endemic nearly two years. From these observa- 
tions, and from the many cases which I have since observed, I am per- 
suaded that, in order to secure the best treatment, constitutional and 
local, of diphtheria, it is necessary that the physician should accept the 
following propositions : 

1st. The specific principle of diphtheria, in all probability, quickly 
enters the blood, in ordinary cases. And after an incubative period, 
which varies from a few hours to seven or eight days, produces the 
symptoms which characterize the disease. 

2d. As in vaccinia the system is infected as soon as the vaccine erup- 
tion appears, so in diphtheria the blood is infected as soon as the pharyn- 
gitis and pseudo-membrane occur. Their intimate relation to the circu- 
latory system, and especially the fact that raising the pseudo-membrane 
lacerates capillaries, and causes bleeding, prevents our believing other- 
wise. 



318 DIPHTHERIA. 

3d. The blood poisoning is probably sometimes septic, but as it ordin- 
arily occurs, it is produced by a specific principle peculiar to diphtheria. 

4th. Facts do not justify the belief that the system can be protected 
by antiseptic or preservative medicines administered internally. A 
quantity of this kind of medicine, introduced into the system, sufficient 
to preserve the blood and tissues from the action of the diphtheritic 
virus, would, there is reason to think, be so large as to arrest molec- 
ular action, and therefore the functions of organs, and occasion death. 

5th. There is no knovrn antidote for diphtheria, in the sense in which 
quinia is an antidote for malarial diseases, and no more probability that 
such an antidote will be discovered than for scarlet fever or typhoid 
fever. 

6th. Diphtheria, like erysipelas, has no fixed duration. It may cease 
in two or three days, or continue as many weeks ; but the specific poison 
acts with more intensity in the commencement than subsequently, and 
its energy gradually abates. Hence, diphtheritic inflammation, which 
arises in the beginning of diphtheria, as laryngitis, is more severe and 
dangerous than when the malady has continued a few days. 

7th. The indication of treatment is to sustain the patient by the most 
nutritious diet, by tonics, and stimulants ; and to employ other meas- 
ures, general and local, as adjuvants, to meet special indications which 
may arise. The rules of treatment appropriate for scarlet fever, apply 
for the most part to diphtheria. Local treatment of the inflammations 
should be unirritating, and designed to prevent putrefactive changes and 
septic poisoning. Irritating applications which produce pain lasting 
more than a few minutes, or which increase the area or degree of redness, 
are apt to do harm, and increase the extent and thickness of the pseudo- 
membrane. 

General Treatment. — This may be conveniently considered under 
the three heads, food, stimulants, and tonics. All physicians of experi- 
ence recognize the importance of the use of the most nutritious and 
easily digested food, and the preservation of the appetite — for the safety 
of the patient requires that he should retain, as far as possible, his flesh 
and strength. The more nutritious and easily digested the food, given 
in sufficient quantity, with the appetite preserved, the less, obviously, 
the danger of the fatal prostration which so frequently occurs suddenly 
and unexpectedly in grave cases. Beef-tea, or the>expressed juice of 
meat, milk with farinaceous food, etc., should be administered every 
two or three hours, or to the full extent, without overtaxing digestion. 
Failure of the appetite, and refusal to take food, are justly regarded as 
very unfavorable signs. One objection to the use of the brush, instead 
of spraying the fauces with the atomizer, is that it is more apt to pro- 
voke vomiting, by which nutriment, that is so much required, is lost. 
In malignant cases of diphtheria, as in scarlet fever of a similar type, 
patients are sometimes allowed to slumber too long without nutriment. 
It is the slumber of toxaemia, and should be interrupted at stated times, 
in order to give food. 

Stimulants. — M. Sanne, in his treatise on diphtheria, says : 
" De tous les antiseptiques donnes a l'interieur, l'alcool est de beau- 
coup le plus sur. Plus l'infection est prononce, plus il faut insister 



STIMULANTS. 319 

sur les composes alcooliques." He states that Bricheteau reports 
the history of a patient, who took daily, during diphtheria, a bottle 
and a half of the wine of Bordeaux, without the least symptom of in- 
toxication or headache. A somewhat similar case was reported to me, 
in which nearly a bottle of brandy was given in less than twenty-four 
hours, without any ill-effect, and an apparent good result on the general 
course of the disease. The same rule holds true in diphtheria as in 
other acute infectious maladies, that while mild cases do well without 
alcoholic stimulants, they are required in cases of a severe type, and 
should be administered in large and frequent doses, whenever pallor and 
loss of appetite, or of strength and flesh, indicate danger from the diph- 
theritic or septic infection. It matters little how the stimulant is admin- 
istered, whether milk-punch or wine-whey, provided that the proper 
quantity is employed. If given early and frequently in grave cases, 
as, for example, one teaspoonful every half hour of brandy or Bourbon 
whiskey, it does seem to have a tendency to render the disease more 
tractable. But to be instrumental in saving life in malignant cases, 
it must be given boldly from the start. If there be marked diph- 
theritic toxaemia when its use is commenced it will not save life, but it 
may prolong it. Although an advocate of the liberal use of alcohol I 
cannot regard this agent as a specific. When I commenced serving in 
the New York Foundling Asylum in May, 1878, the quarantine wards 
contained four children, between the ages of three and five years, who 
had been sick a few days with severe diphtheria, and it was evident at 
a glance that they must soon perish with the ordinary mild sustaining 
treatment. Quinine, iron, the most nutritious food, and a moderate 
amount of alcoholic stimulants were being given, and we determined to 
increase the Bourbon whiskey to one teaspoonful every twenty to thirty 
minutes, day and night. Nevertheless, whatever the result might have 
been with the earlier commencement of this treatment, the blood poison- 
ing was now too profound, and one after the other died. That intoxi- 
cation is so seldom produced in this disease by frequent and large doses 
of the alcoholic compounds is due partly to the quick elimination of 
such substances from the system, and in part, probably, to the nature 
of diphtheria. 

In fulfilling the indication for sustaining treatment, the vegetable 
tonics have been long used, especially cinchona and its alkaloid principle 
quinia. The compound tincture of cinchona, and the fluid extract, have 
been used and recommended by physicians of experience ; but of vege- 
table agents, quinia has long been and still is more frequently prescribed 
than all others. But the doses employed vary greatly in size and fre- 
quency, in the practice of different physicians. It is administered in 
large doses for its antipyretic effect, so that twenty or thirty grains are 
given daily, and in small doses, as one to two grains every fourth hour, 
for its tonic effect. That there is nothing antagonistic in the action of 
quinine to the diphtheritic virus, and that it is beneficial in the same 
way, and no further, than in other acute infectious diseases, is, I think, 
generally admitted by the profession. Large and frequent doses appar- 
ently produce no amelioration in the severity of the disease, or diminish 



320 DIPHTHERIA. 

the degree of blood-poisoning, as is shown by cases like the following, 
which are not infrequent during severe epidemics. 

C, aged four years, male, was examined by me in consultation, on 
February 10, 1876. I learned that he had apparently contracted diph- 
theria from the escape of sewer-gas through a defective trap in the little 
room where he slept, and that the disease began after midday on February 
6th, with fever. At 10 p. m. of the same day, when visited by the family 
physician, the temperature was 103°, and the fauces were red, but without 
any psuedo-membrane. Four grains of quiuia were ordered to be given 
every two hours, and ten drops of the tincture of the chloride of iron, 
with two grains of the chlorate of potassium, to be given three times 
hourly. On the 7th the exudation covered both tousils and the half 
arches; temp. 102*°; evening temp. 100°; pulse 128. 8th. Is playful; 
pulse 100 ; has slight swelling of the cervical glands ; evening, some ex- 
tension upward of the pseudo-membrane ; has vomiting. 9th. Pulse 144; 
vomits often. 10th. At 3 p. m. began to grow worse ; pharynx and nos- 
trils covered with the exudation. From this time the case rapidly 
advanced to a fatal termination. 

It was impossible at the time of my visit to obtain the urine for exami 
nation and death occurred a few hours afterwards. Forty-eight grains 
of quinia daily, administered from the first day, had no appreciable effect 
in staying the fatal progress of the malady, had no such effect as would 
be likely to follow were its action antidotal, or did it tend to prevent or 
dimmish the blood poisoning. As an antipyretic, I am justified in 
saying from our experience in the New York Infant Asylum and Xew 
York Foundling Asylum, that quinine is inferior to salicylate of sodium, 
both in symptomatic and constitutional fevers ; but as it is a tonic, and 
does not impair digestion, it is to be preferred to any other medicine in 
diphtheria, when the febrile movement is so great that an antipyretic is 
needed. Great elevation of temperature, however, seldom occurs in 
diphtheria after the third or fourth day, for when symptoms of blood 
poisoning occur the temperature is apt to fall, so that in profound toxaemia 
it is often not more than 101° or 102°, and the indication for quinine 
is then not for its antipyretic but tonic action. The following is a pre- 
scription for this agent as a tonic for a child of five years. 

R. — Quinise sulphat gss. 

Syr. pruni virginiani ; 

or, 
Elix. tarax. comp. ^ij. — !Misce. 

Give one teaspoonful every two to four hours. 

All physicians who are familiar with diphtheria have noticed the 
pallor, loss of appetite, flesh and strength, which commence before the 
close of the first week in severe cases, and which are always unfavorable 
svmptoms, indicating, as they do, rapid and progressive deterioration of 
the blood. The use of iron is at once suggested as the proper medicinal 
remedy to arrest this blood change, from its known effect in increasing 
the number of red blood-corpuscles, and the. quantity of coloring matter in 
these corpuscles, and the nutritive elements in the blood. By its effect 



STIMULANTS. 321 

on the red corpuscles, which are the carriers of oxygen, it increases the 
functional activity of organs, and improves the general nutrition. The 
ferruginous preparations, therefore, hold an important place in the 
therapeutics of diphtheria. The one which has long stood the test of 
experience, and is now commonly used, is the tincture of the chloride of 
iron. It should be given in large and frequent doses, as five drops 
hourly, to a child of three to five years. 

The inflammations, so far as they are accessible, should be treated by 
local measures, but we may combine with the iron one which exerts a 
decidedly curative action on buccal and pharyngeal inflammations, which 
is a solvent of pseudo-membranes, and which, after it enters the system, 
being largely eliminated from the salivary glands, continues after the 
dose is taken to have eifect on the inflamed surface of the buccal cavity 
and fauces. This medicine, namely, the chlorate of potassium, has of 
late years become a domestic remedy, but the laity should be cautioned 
in reference to its use. It is an irritant to the kidneys in large doses, 
producing intense inflammatory congestion of these organs and arresting 
their function. The melancholy fate of Dr. Fountaine more than a 
quarter of a century since, whose life was sacrificed by an experimental 
dose of one ounce of this agent, is remembered by the older physicians. 
A few years since in my own practice a child of about three years, with 
an active pharyngitis, probably diphtheritic, and a temperature of 103°, 
was allowed to quench its thirst between evening and morning, by drink- 
ing from a small pitcher in which three drachms of chlorate of potassium 
were dissolved. In the morning I was summoned in haste, and found 
the surface of the patient cold and blue, and pulse feeble. The urine 
was totally suppressed, and instead of it a few drops of blood passed 
from the urethra. Death occurred before night. The chlorate had 
apparently produced some irritation upon the intestinal surface, but the 
fatal result was evidently due to the state of the kidneys. A child of 
three years should not take more than three grains at a dose, and no 
more than one drachm in twenty-four hours. The following will be 
found useful prescriptions : 

R. — Tine, ferri chloridi gij. 

Potas. chlorat zj. 

Syr. simplic. ....... 3 iv. — Misce. 

Dose, one teaspoonful every hour to two hours for a child of three years. In 
place of the simple syrup three parts of water and one of glycerine may be em- 
ployed. 

R. — Tine, ferri chloridi gij. 

Acidi sulphurosi 

Potas. chlorat. .... 

Glycerinae 

Aq. calcis ...... q.s. ad. ^iij. — Misce. 

Dose, one teaspoonful every hour to two hours for a child of three years. 

The citrate of iron and ammonia alone, or in combination with car- 
bonate of ammonium, may be given in two-grain doses, dissolved in 
simple syrup, in place of the above mixture, when the inflammation of 
the fauces has considerably abated or is moderate ; or the beef, iron, and 
wine of the shops may be given every hour or second hour. If the 

21 



3.1- 
5.1- 



322 DIPHTHERIA. 

patient improve, and the disease begin to decline, the intervals between 
the doses may be lengthened, but the tonic should not be entirely dis- 
continued until the patient is far advanced in recovery, on account of 
the dangerous sequelae which take their origin in an impoverished state 
of the blood. 

Local Treatment. — It is important to keep in mind the purpose 
for which local measures should be employed, as stated above. It is to 
reduce the inflammation of the mucous surfaces, and destroy the diph- 
theritic poison and contagious properties in the pseudo-membrane, and 
to destroy the septic poison, and prevent its absorption, if any form. 
Forcible removal of the pseudo-membrane, irritating applications, the 
use of a sponge or other rough instrument, for making the applications, 
should be avoided as likely to do harm. The applications should be 
made either with a large camel's-hair pencil, or, better for most of the 
mixtures employed, with the atomizer. The hand atomizer, like Rich- 
ardson's hard rubber, or Delano's, which is of simple construction, while 
it carries a heavy spray from the curved tube, which is introduced over 
the tongue, is very useful. 

Half a dozen to a dozen compressions of the bulb of the hand atom- 
izer cover the surface of the throat more effectually with the liquid than 
can be done by several applications of the brush, and it is usually not 
dreaded by the patient. Diminution in size of the pseudo-membrane 
under the use of the spray is a favorable sign, but if it do not diminish, 
its presence can do little harm, provided that it is properly disinfected. 

The steam atomizer may also be used, and in some cases it is more 
convenient than that worked by the hand, but the medicine employed 
in it is necessarily much diluted by the steam from the boiler, unless 
it be of such a nature that it can be used in both cup and boiler. The 
steam atomizer possesses the advantage of producing a steady spray, 
without exciting or disturbing the patient, so that it can be inhaled 
even during sleep, but it is best often to supplement its action by the 
hand instrument. The hand atomizer is less apt to be clogged than 
the delicate glass points of the steam instrument, and will vaporize a 
thicker liquid. This is an important advantage, especially in using 
the lime-water for inhalation in croup, since it can be employed in the 
hand atomizer even when it presents a milky appearance from the 
amount of lime. 

At a recent meeting of the New York Pathological Society I pre- 
sented a specimen showing the diphtheritic exudation, and a discussion 
arose as to what is the safest and most efficient solvent of the false 
membrane, full and exact knowledge of which is very important, espe- 
cially for correct treatment of diphtheritic croup. Chlorate of potas- 
sium, pepsin, lactic acid, and lime, are solvents of pseudo-membranes, 
and after the meeting of the Pathological Society Dr. Chadbourne, 
resident physician of the New York Foundling Asylum, and myself, 
determined to ascertain experimentally which is the best solvent. We 
employed reliable liquid pepsin, acidulated with lactic acid, thirty 
drops to the ounce, for one solvent, and the officinal lime-water for the 
other. Equal portions of pseudo-membrane, removed from the larynx 
in a fatal case of diphtheritic croup, were added to the same quantity 




LOCAL TREATMENT. 323 

of these liquids. The lime-water produced complete solution in about 
twenty-five minutes, while the lactic acid and pepsin required more 
time. I have repeated the experiment since, with a similar result, and 
have employed the lime-water mixed with about one-fourth its quantity 
of carbonic acid water, but this did not seem to impair materially the 
solvent power of the lime. This last experiment was made in order to 
determine whether the carbonic acid, which passes over the pseudo- 
membrane in each expiration, impaired the solvent action of the lime. 

Therefore in the local treatment of diphtheritic pharyngitis, plain 
lime-water is one of the best solvents of the pseudo-membrane used by 
the atomizer or gargle, preferably by the former, or one of the following 
mixtures may be employed : 

No. 1. 

R. — Acid, carbolic. gss. 

Aquae calcis. . . . . . . . 3viij. — Misce. 

No. 2. 
R . — Acid, carbolic. ....... 

Potas. chlorat 

G-lycerinae ... 

Aquas . 

More recent investigations, conducted by Dr. Chadbourne, have 
shown that liquor potassee, or liquor sodse, one part to forty of water, 
is a still more active solvent of fibrin. For further particulars relating 
to these investigations the reader is referred to our remarks on the 
treatment of pseudo-membranous laryngitis. 

Employ atomizer every hour or second hour. India-rubber tubing, 
which does not interfere with the action, should be drawn over the sharp 
point of Delano's atomizer. In this connection, I would state that the 
hand atomizer with double bulb is preferable to that with single bulb, 
as the child tolerates better the steady spray. The advantage of its use 
is very notable in the treatment of diphtheritic croup. 

In most cases of diphtheritic inflammation of the fauces the spray 
suffices for local treatment, but the following mixture, applied by a 
large camel's-hair pencil, is also very effectual, immediately converting 
the pseudo-membrane into an inert mass, and putting a stop to all 
movements of the bacteria which swarm in it, as I have observed under 
the microscope : 

R. — Acid, carbolic gtt. viij. 

Liq. ferri subsulphat. ...... gij-iij. 

Glycerine . gj. — Misce. 

This may be used two or three times daily, between the spraying, or 
oftener without the spraying. It is not irritating (such an effect would 
condemn it), but it is dreaded by most children, on account of the 
unpleasant "puckering" which it produces, and the pain from the 
contraction, which sometimes extends to the ear. 

That form of diphtheritic inflammation which most imperatively 
requires local treatment, and in which local measures are of more 
importance than the constitutional, is obviously the laryngeal. Catar- 
rhal laryngitis sometimes occurs in diphtheria, as I have occasionally 



324 DIPHTHERIA. 

observed in the dead-house, without producing any marked symptoms, 
but the pseudo-membranous laryngitis of diphtheria is also common, 
and, as all know, is one of the most dangerous forms of disease. It is 
treated of elsewhere in this volume. 

Diphtheritic paralysis requires the use of strychnine with tonics. I 
ordinarily employ the elix. phosphat. ferri qui. et strychniae of the 
shops. Each drachm of this contains gr. ^ of strychnia, and by dilu- 
tion with water the proper dose can be administered to a child of any 
age. Thus, recently, a child aged six years, having paralysis of the 
muscles of the pharynx, recovered in about one week, by the use of 
one drachm of this medicine daily, given in four or five doses. I have 
not found it necessary, in any case which I have observed, to employ 
electricity, but it is no doubt useful in expediting recovery, especially 
if the paralysis be in the limbs. The anaemic state which succeeds 
diphtheria requires the use of iron for several weeks in the paralytic as • 
well as non-paralytic cases. 

For the treatment of nasal diphtheria, a mixture like the following 
should be injected warm into each nostril every two to four hours : 

K- — Acidi boracic. gij. 

S<'dii cliloridi . . . . . . . gj- • 

Aquse Oj. — Misce. 

Warm lime-water may also be used for this purpose. 

Preventive Measures. — The occurrence of diphtheria in a family 
necessitates the prompt removal of other children of the family either 
out of the house or to a distant part of it, and the disinfection of the 
room, and the handkerchiefs, and other linen, and spittoons employed. 
The diphtheritic, like the scarlatinous, virus may remain for weeks or 
months in a locality or apartment. In East Fifty-fifth Street two 
families resided in a brown-stone house, the sanitary condition of which 
was apparently good. In December, 1874, diphtheria occurred in one 
of these families, who occupied the lower floor and the basement, causing 
the death of two of the children. The other family, in order to escape 
the danger, immediately removed to another part of the city, where 
they remained two months, returning home on March 6th. On March 
14th and 15th, eight and nine days after the return, their two children, 
aged 5J and 4J years, who had been allowed free access to the room in 
which the fatal cases had occurred, also took severe diphtheria, one of 
them dying. 

In another family, living in the suburbs of New York, a lady con- 
tracted diphtheria from her brother's child, who died of the malady a 
few blocks distant. Returning home, she occupied a small room, re- 
maining constantly in it, and by prompt treatment was soon con- 
valescent. Her only child, a boy of six years, was excluded from her 
companionship about one month, after which he was allowed to enter 
the room, and slept in it. Within a few days, namely, thirty-five days 
after it commenced in the mother, the diphtheritic patch appeared upon 
his fauces. In one of the asylums of this city, diphtheria has been pre- 
vailing more than a year, the cases occurring mainly in one of the 
buildings, and with so little break or intermission that it appears that 
the diphtheritic virus has not been eradicated from one or more of the 



PERTUSSIS. 325 

wards since the first case occurred. Such instances show the danger 
of admitting children into rooms where diphtheria has occurred, until 
a considerable period has elapsed, and thorough disinfection has been 
employed. 

When diphtheria is prevalent, indisposition on the part of a child, 
and especially febrile symptoms, or defiuxion from the nostrils, should 
at once arrest attention. Although there be no complaint of soreness 
of the throat, the fauces should be carefully inspected, and if they seem 
too red, they should be sprayed with one of the mixtures recommended 
above. 

Pertussis. 

Pertussis is an infectious disease attended and manifested by a 
catarrh of the air-passages. This catarrh gives rise to a cough which 
does not differ, during the inception and in the declining period, from 
that in an ordinary catarrh, but during the middle period of the malady 
is spasmodic. Exceptionally the system is so mildly aifected that the 
spasmodic element of the cough is lacking through the whole course of 
the malady, or is confined to a brief period. This distinctive symptom, 
namely, the peculiar cough, has been attributed to the irritating and 
disturbing action of the specific principle on the nerves which control 
the muscles of respiration. Some attribute it to the impression pro- 
duced upon the filaments of the pneumogastric, especially upon those 
of the internal branch of the superior laryngeal nerve, by the mucus 
which collects in the larynx and trachea, and which is known to con- 
tain the contagious principle in abundance. This cough consists in a 
series of forcible and loud expirations, followed by a noisy and difficult 
inspiration. Its special character is due to spasmodic contraction of 
the muscles of expiration, and notably of the small muscles of the larynx 
so as to produce narrowing or even closure of the aperture of the glottis. 
Each paroxysm of the cough usually ends, not always, in the expecto- 
ration of viscid mucus. With rare exceptions pertussis affects the same 
individual but once. Rilliet and Barthez report a case of its second 
occurrence, and West another case. I have attended two adult 
patients, both Avomen of intelligence, who stated that they had had 
previous attacks in early life. Pertussis usually prevails as an epi- 
demic, but is occasionally sporadic, at which time its type is mild. It 
is highly contagious through the breath of the patient, or from exhala- 
tions from his surface. 

In one instance I was able to ascertain accurately the incubative 
period of pertussis. Mrs. B., having a cough for two weeks, which was 
afterwards ascertained to be that of pertussis, came from Boston to a 
family in New York. She remained with this family from 2 p. M., 
January 2, 1879, till the evening, when she left the city. During her 
stay she held and kissed an infant that was previously well, and had 
never been removed from the floor on which it was born. Pertussis 
was not at that time prevailing in New York. On the 6th, or four 
days after exposure, the infant began to cough, and this proved to be 
the beginning of a severe pertussis. 



326 PERTUSSIS. 

Age. — Most cases of pertussis are between the ages of one year and 
eight years, but it occasionally occurs in adults and even old people 
who have not been attacked previously. It is rare under the age of 
three months, but through the kindness of Dr. Ewing, of New York, I 
was enabled to see a newborn infant with pertussis, whose mother had 
had the disease during the two months preceding her confinement. 
This infant when fifteen minutes old, and during the washing, had the 
first convulsive seizure, which appeared to consist chiefly of a spasm of 
the laryngeal muscles, with temporary suspension of the respiration, 
and attended by deep lividity of the features, with some frothing from 
the mouth. ' These attacks occurred nearly every hour, with intervals 
of complete cessation of symptoms. The mucus between the lips 
finally became stained with blood, and death occurred on the third day. 
The mother, the intelligent wife of a clergyman, believes that the infant 
had similar attacks before its birth, for she frequently experienced in 
the last weeks of gestation what seemed to be strong convulsive move- 
ments in the foetus, the duration of which corresponded with that of the 
attacks in the infant. A similar case is related by Rilliet and Barthez, 1 
and another by Keating. 2 These cases throw light on the pathology of 
pertussis, for they show that the specific principle resides in the blood, 
and that this disease is therefore general or constitutional, and is not 
localized on the respiratory surfaces as some have held ; or if the specific 
principle resides in or upon the laryngo-tracheal surface, it must, in 
some cases, if not in all, infect the blood, else it could not be contracted 
in the foetal state. 

Causes. — Climate, race, and nationality do not seem to exert any 
decided influence on the spread of pertussis. Females are somewhat 
more liable to be attacked than males, and, as we have seen, a large 
maj ority of the cases occur between the ages of one and ten years. Letze- 
rich, about the year 1870, supposed that he had discovered the cause of 
pertussis in a fungus, which, received upon the surface of the air-passages 
in inspiration, increases rapidly and produces the spasmodic cough by 
its irritating action, or the irritating property which it imparts to the 
mucus. In the first stage of pertussis he found only the spores of the 
fungus, and at a more advanced stage in addition to the spores, he dis- 
covered branches of the thallus. He placed mucus holding the cryp- 
togam upon the fauces of the rabbit, and witnessed the production of 
pertussis in this animal. Recently Burger, 3 of Bonn, states, "that the 
microorganism of pertussis is visible with a power of 340 to 600 diam- 
eters, appearing as little rods of unequal size. With a higher power it 
is seen that the rods have the biscuit form. The groups of bacteria are 
irregularly disseminated or disposed in line, and somewhat resemble the 
leptothrix buccalis. The method of preparation is very simple. A 
small quantity of the expectoration is pressed between two cover glasses, 
exposed to the flame of a Bunsen burner to coagulate the albumen ; the 
coloring matter is then added (watery solution of fuchsin, or of 
methyl violet) ; it is then washed thoroughly in water, or the coloring 

1 Treatise on the Diseases of Children. 

2 System of Medicine by American Authors; Lea Bros., Philadelphia, 1885. 

3 Berlin, klin. Wochenschrift ; London Medical Record, May 15, 1884. 



PATHOLOGICAL ANATOMY. 327 

matter removed by washing in alcohol, the bacteria alone remaining 
colored. These bacilli are not found in any other expectoration ; they 
are so abundant, that it is difficult to contest their action, their fre- 
quency is always in direct relation with the intensity of the disease." 
Dr. Poulet 1 also confirms the statement of a special microorganism in 
pertussis, from his examinations. But no one has yet employed the test 
of Pasteur with the supposed pertussis microbe, to wit, cultivation. We 
will accept as certain, the discovery of this microbe, if it have passed 
through a series of cultivations, and the disease be reproduced with the 
last product either in man or in some animal as the rabbit. 

Lesions have been discovered in certain fatal cases which have been 
supposed to throw light on the etiology of pertussis, but which are now 
known to have been merely coincidences or results of the disease. Such 
are congestion of the spinal cord and its meninges, hypersemia of the 
pneumogastrics, and tumefaction of the tracheo-bronchial glands, which 
it was claimed produced the spasmodic cough by compressing the recur- 
rent laryngeal nerve. 

Pathological Anatomy. — Catarrhal inflammation of the air-passages 
is uniformly present. It occasionally occurs on the mucous surface of 
the nostrils and pharynx, but is often absent from these parts. In the 
majority of patients the inflammation affects the surface of the glottis and 
that below the glottis. However, in not a few cases the surface of the 
larynx and trachea is pale and not swollen, or the inflammatory appear- 
ance is limited to a small part, as the ventricles of the larynx, while the 
mucous coat of the bronchi and their branches is swollen and red, and 
covered with tenacious mucus. Sometimes certain alveoli are found 
distended by a thick muco-pus, producing an appearance like minute 
tubercles. 

A common lesion found in the lungs of those who have perished with 
this malady is emphysema, affecting chiefly the peripheral portions of 
the upper lobes. It is usually vesicular emphysema occurring from 
over-distention of the air-cells, but in some instances the air has escaped 
into the connective tissue, causing interstitial emphysema. According 
to my recollection of fatal cases, which have occurred from time to time 
in the institutions of New York, and in which I have made post-mortem 
examinations, the upper lobes were exsanguine and inflated to nearly 
the fullest extent possible within the thorax, while other portions of the 
lungs presented areas of pneumonic, or more or less complete atelectatic 
solidification. Pneumonia, atelectasis, and small extravasations of blood 
in the lungs, are, indeed, common lesions. Hyperplasia of the bronchial 
glands is also common, and hyperplasia has also been occasionally ob- 
served of other lymphatic glands, as the mesenteric. An ulcer under 
the tongue which observers have frequently noticed is now attributed to 
pressure of the tongue on the lower incisors during the cough. 

In fatal cases, small extravasations of blood in or upon the brain are 
common, as is also passive congestion of the sinuses, veins, and capilla- 
ries, meningeal and cerebral, attended with more or less transudation of 
serum within the ventricles of the brain, and between the meninges. 

1 Le Scalpel ; London Medical Becord, May 15, 1884 



328 PERTUSSIS. 

Large dark and soft clots, and occasionally some that are white or yellow, 
are common in the infra-cranial sinuses, especially if, as often happens, 
death have occurred in convulsions, which supervened upon the severe 
spasmodic cough. 

Symptoms. — Pertussis consists of three stages : first, that of catarrh 
of the air-passages ; secondly, the stage of spasmodic cough, or, for 
brevity, the spasmodic stage ; thirdly, the stage of decline. 

The first period is characterized by the symptoms of coryza and bron- 
chitis, which present nothing peculiar or different from ordinary catarrh 
of the same parts, unless occasionally the cough be more frequent and 
teasing. Trousseau has known it to be repeated forty or fifty times per 
minute. The eyes present a moderately suffused appearance, and there 
is sneezing, with defluxion from the nostrils, but less than in the com- 
mencement of measles. The cough, which commences as soon as the 
catarrh affects the larynx, is accompanied by little or no expectoration. 
The pulse and respiration are moderately accelerated, and such other 
symptoms as commonly accompany catarrh of a mild grade are present, 
namely, increased heat of surface, thirst, and impaired appetite. 

The duration of the first stage varies in different cases. In severe 
hooping-cough it' may last only two or three days, and in mild cases be 
protracted to five or six weeks. It may be absent especially in very 
young infants. We have alluded above to the newborn infant, in whom 
there was no first stage, a glottic spasm occurring soon after birth. The 
first stage commonly ends in from eight to fifteen days. In fifty-five 
cases observed by Dr. West its average duration was twelve days and 
seven-tenths of a day. It is stated above that the first stage in rare 
instances continues during the entire course of pertussis ; at least no 
spasmodic cough occurs. In two such cases which I now recall to mind, 
both girls, the inflammatory symptoms abated someAvhat after the first 
few days, and an occasional easy cough remained, like that of simple 
bronchitis, and it continued during a period corresponding with the 
ordinary duration of pertussis. The diagnosis would have been doubtful, 
except for the occurrence of pertussis, with its regular stages, in other 
children of the same families. 

Second Period. — This may commence quite abruptly, but ordinarily 
its beginning is gradual. While the cough commonly has the character 
present in the first stage, it is now and then observed to be more severe 
and spasmodic, especially at night, and when the patient is in any way 
excited. The spasmodic element increases, so that in the course of a 
week all doubt as to the nature of the disease is removed. 

The severity of the cough in the second stage varies considerably in 
different cases. It sometimes commences quite abruptly, with little 
warning, but commonly there is premonition of it, and the child endeav- 
ors to repress it. He experiences a tickling sensation in the throat, or 
median line of the chest, or a feeling of constriction. He leaves his 
playthings, and rests his head on his mother's lap, or takes hold of some 
firm object for support; his face has a grave or even anxious appear- 
ance, while the pulse and respiration are somewhat accelerated. Imme- 
diately the cough begins. It consists in a series of short and hurried 
expirations, which expel a large part of the air contained in the lungs, 



SYMPTOMS. 329 

followed by a hurried inspiration, which is difficult and noisy on account 
of the spasmodic contraction of the laryngeal muscles, and narrowing 
of the glottic aperture. The sound which accompanies the inspiration, 
and which is often absent, especially in infants is designated the hoop. 
The forcible expirations, and difficulty experienced in expelling the 
air from the lungs on account of the constriction of the glottis, afford 
explanation of the emphysematous distention of the air-cells in the 
upper lobes, which we have seen is so common in severe pertussis. 

There may be a single series of expirations terminating in the man- 
ner stated, but often there are several such series embraced in a par- 
oxysm. The cough commonly ends in the expulsion of frothy mucus 
from the bronchial tubes, and sometimes in vomiting. During the 
cough there is temporary arrest of blood in the lungs, leading to con- 
gestion in the right cavities of the heart, and throughout the systemic 
circulation ; therefore the face is flushed and swollen, and occasionally 
hemorrhage occurs under the conjunctiva, or from one of the mucous 
surfaces. The most frequent hemorrhage is epistaxis. When the 
cough ceases, the normal respiration is restored, the fulness of the 
vessels immediately abates ; but often puffiness of the features is ob- 
served, due to serous infiltration of the subcutaneous connective tissue, 
and continuing for days or weeks during the period when the cough is 
most severe. The paroxysm lasts from a quarter to a half or even a 
whole minute, and in that time, in cases of ordinary severity, there are 
often as many as fifteen or twenty series of expirations. 

At the close of the paroxysm, if there be no complication, the symp- 
toms soon abate ; the temperature, pulse, and respiration become normal, 
and there is no evidence of disease. The cough in the second stage is 
much more frequent in one case than another. At the height of this 
stage it is generally more severe if it occur at long intervals than when 
frequent. During the weeks in which pertussis is most severe, there is, 
in the average, about one paroxysm of coughing in each hour. 

The cough increases in severity till the third week of the second 
stage, or the thirtieth to thirty-fifth day of the disease, after which it 
remains stationary for a certain time. It is apt to be more frequent in 
the night than daytime. Sometimes it occurs while the child is quiet; 
it may even awaken him from sleep, but it is often also produced by 
mental excitement or by physical exertion. Anger or fright gives rise 
to it, and therefore the child is apt to cough when being examined by 
the physician, or when his wishes are not complied with. The ordinary 
duration of the second stage is from thirty to sixty days. It may, how- 
ever, be considerably longer or shorter than this. 

The third staje, which commences at the time when the spasmodic 
cough begins to abate, is short, not continuing longer than two or three 
weeks. A protracted stage of decline indicates some complication. 
While the sputum in the second stage is mucous and frothy, that in the 
third stage is more opaque and puriform*. 

In the third as in the second stage, if there be no complication, the 
pulse and respiration in the intervals of the paroxysms are nearly or 
quite natural. Febrile excitement, may, however, now and then occur 
from trifling causes, or, indeed, without any apparent cause. The 
digestion and the general health in uncomplicated pertussis remain un- 



330 PERTUSSIS. 

impaired, with the exception of more or less emaciation, which is apt to 
occur in all but the mildest cases, in consequence of the frequent vomit- 
ing. After complete recovery, it is not unusual for the spasmodic cough 
to reappear at times, for one or even two years. The cough of ordinary 
simple laryngitis, or bronchitis, assumes this character. 

Complications. — These, like the symptoms, are chiefly of a twofold 
character, namely, inflammatory and neuropathic. From the nature of 
the- cough in pertussis, it would naturally be supposed that the spas- 
modic affection which is now designated internal convulsions, and which 
is characterized by spasm of certain muscles of respiration would be a 
frequent complication. It does sometimes occur in young children, but 
it is not common. Clonic convulsions affecting the external muscles are, 
on the other hand, not infrequent. They occur chiefly in the second 
stage, when the cough is most severe, and in infancy much more fre- 
quently than in childhood. They are apt to be general and severe, or 
if not of this character at first, to become such. The convulsions com- 
mence, in most instances, in or directly after the paroxysm of coughing; 
but they sometimes occur in the interval when the child is quiet. 

Rilliet and Barthez remark: "Almost all infants succumb to this 
complication, ordinarily in the twenty-four hours which follow the first 
attack ; nevertheless, life may be prolonged during two or three days." 
(Article Coqueluche.) In my own practice this complication usually 
ended fatally before bromide of potassium and chloral were employed, 
but with the proper use of these agents it can often be arrested. In 
the month of June, 1857, I was attending a little girl two years and 
four months old, who had reached the fifth week of pertussis, when she 
was seized with general clonic convulsions. The mother, who was re- 
quested to keep a record of the number of convulsions, stated that there 
were twenty in all, occurring within forty-eight hours. They affected 
both sides, the shortest lasting only three or four minutes, the longest 
seventy-five minutes. The treatment in this case, which eventuated 
favorably, will be noticed hereafter. 

In those who die of convulsions occurring in hooping-cough, the most 
constant lesion is congestion of the cerebral veins and sinuses, often with 
transudation of serum. This congestion is due in part to the cough which 
precedes the convulsions and in part to the convulsions themselves. 
At the autopsies which I have made of two infants, who died in hos- 
pital practice from hooping-cough, accompanied by convulsions, all the 
cerebral sinuses were filled with clots, which were generally soft and 
dark ; but in the lateral sinuses clots were found which were light- 
colored. The light color of a clot, either in a vein or sinus, indicates 
its ante-mortem formation. 

The gravity of the convulsive attack can bo ascertained by observing 
whether the patient readily recovers consciousness. Its return indi- 
cates that there is no serious congestion. On the other hand, great 
drowsiness remaining, or a semi-comatose state, indicates persistent 
congestion, and, perhaps, even the formation of clots in the sinuses of 
the brain. Death from convulsions is usually preceded by coma. 
Occasionally meningeal apoplexy supervenes upon the congestion, and 
death is immediate. 

The most frequent inflammatory complications are bronchitis and 



COMPLICATIONS. 331 

pneumonitis. Inflammation of the bronchial tubes of a mild grade, we 
have seen, is a common accompaniment of pertussis, but when it 
extends to the minuter tubes, or becomes so severe as to cause accele- 
ration of respiration, it is, properly, a complication. Both bronchitis 
and pneumonitis, occurring as complications, are developed, with few 
exceptions, in the second stage. Bronchitis is accompanied by accele- 
rated respiration and pulse, and increased temperature. The danger 
is proportionate to the amount of dyspnoea. 

Pneumonitis is a less common complication than bronchitis, but it 
occurs more frequently in pertussis than in any other constitutional 
malady of early life, excepting measles. The congestion which results 
and remains in the lung when the cough is frequent and severe, favors 
the development of pneumonia. The symptoms and physical signs 
which accompany this inflammation and serve for its diagnosis are the 
same as in the primary form of the disease, and are described else- 
where. Bronchitis or pneumonia usually moderates the severity of 
the spasmodic cough, for when the inflammatory element in pertussis 
increases, the spasmodic abates. On the abatement of the inflamma- 
tion, however, the cough usually regains its former convulsive character. 
The fact may be stated in this connection, that any complication or 
intercurrent disease which is attended by decided febrile reaction, 
ordinarily renders the cough for the time less spasmodic. 

The occurrence of bronchitis or pneumonia is shown by the elevated 
temperature, acceleration of pulse and respiration, short and frequent 
cough. These symptoms do not cease so long as the inflammation con- 
tinues, whereas in uncomplicated pertussis the patient seems nearly or 
quite well between the coughs. In pneumonia the respiration is accom- 
panied by the expiratory moan, and in both bronchitis and pneumonia 
there is more or less depression of the infra-mammary region during 
inspiration. These symptoms, in connection with the physical signs, 
render diagnosis in most instances easy. Although the general char- 
acter of the cough is changed, a cough now and then occurs, even when 
the inflammation is pretty severe, sufficiently spasmodic to indicate the 
nature of the primary affection. Capillary bronchitis and pneumonia 
are always serious complications. 

Not only is more or less emphysema a common complication of 
severe pertussis, but bronchiectasis also occurs in certain cases, due to 
the same conditions. Emphysema is a common lesion in young and 
feeble infants, even when there is no history of any previous severe dis- 
ease of the respiratory organs. I have found it one of the most com- 
mon lesions in infants of feeble constitutions, who die in the hospitals 
and asylums of New York, but it is usually interstitial and confined 
to a small part of the upper lobes. It is not accompanied by that 
general distention of the alveoli and consequent enlargement of the 
lobes which occur in the emphysema of pertussis. Its chief cause in 
these feeble and wasted infants appears to be impaired nutrition and 
change in the molecular condition of the pulmonary tissue. The same 
condition often occurs in severe and protracted pertussis, and therefore 
serves as an additional and efficient cause of the emphysema. 

The following was a not unusual case of this disease as it occurs in 
the tenement houses and asylums of New York. At the meeting of 



332 PERTUSSIS. 

the New York Pathological Society, October 14, 1868, I exhibited 
emphysematous lungs, removed from an infant who died at the age of 
nineteen months, at the commencement of the fourth week of pertussis. 
Death occurred from thrombosis in the lateral sinuses of the cranium, 
resulting from the severe spasmodic cough, eclampsia, and feebleness 
of the circulation, as the infant was previously in a reduced state from 
chronic entero-colitis. At the autopsy the superior lobes of both lungs 
were found exsanguine, doughy to the feel, and enlarged so as to rise 
above the level of the other lobes. The resiliency and elasticity of the 
lung tissue in these lobes were evidently greatly impaired, and their 
air-cells in a state of over-distention. The other lobes were healthy, 
except that one of them was the seat of catarrhal pneumonia. In this 
case there had been no disease affecting the respiratory apparatus, pre- 
viously to the pertussis, so that the incipient vesicular emphysema was 
referable to the severe cough and impaired nutrition of the lungs. 

Occasionally we meet cases of severe pertussis in which, while there 
is over-distention of the alveoli of the upper lobes, collapse occurs over 
a greater or less extent of the lower lobes. Collapse, like emphysema, 
may continue for weeks or months subsequently to pertussis, and then 
gradually disappear, but in the following rare case in my experience it 
was permanent. John O'Neil, aged 5 J years, was brought to the 
Bureau for the Relief of the Out-door Poor in New York, in December, 
1876. He lived in the underground basement of a tenement-house, 
and was supported by charity, except at intervals, when his father, who 
was dissipated, could obtain work. At the age of fifteen months he had 
a glandular swelling on the right side of the neck, which suppurated, 
and three months later one on the opposite side, which also suppurated. 
At the age of 2 J years he had bronchitis, the cough of which did not 
abate till two months subsequently. When near the age of three years 
he had measles, and the cough from this disease lasted three or four 
months. In the summer of 1875, or about one year subsequently to 
the measles, he contracted pertussis, which was severe, but was allowed 
to run its course without treatment. It lasted four months, never, how- 
ever, confining him to bed or materially impairing his appetite. One 
morning about the close of the second month of the malady, the parents 
first observed depression of the right side of the thorax. This gradually 
increased for a few weeks and has been permanent. * The parents stated 
that he had never been confined to the house or without appetite except 
during the week of measles. 

Since his recovery from pertussis he has had his usual appetite and 
general health, but crying or excitement commonly brings on a pretty 
severe cough. The depression of the thorax examined in front, begins 
quite abruptly in the line of the left costo-chondral articulations. Cir- 
cumferential measurement of the left side from the middle of the sternum 
to the spine, the tape lying a little below the nipple, gives eleven and a 
half inches, while corresponding measurement of the right side gives 
seven and a half inches ; pulse 136, sounds of the heart normal ; respira- 
tion 44. On auscultation over the right side of the chest we observed 
bronchial respiration, and a feeble bronchophony, with perhaps slight 
vocal fremitus. The accompanying figure is from a photograph by Mr. 



DIAGNOSIS. 



Fig. 24. 



Mason, photographer to Bellevue Hospital. My first impression on 

observing this case was that it was one of unexpanded lung, which had 

been compressed by a pleuritic effusion, but it is seen that the history 

points clearly to pertussis as the cause of the 

deformity. The depression occurred somewhat 

suddenly when the cough was most severe, and 

when there was no fever, loss of appetite, or 

other symptom of pleuritis. The patient had 

not presented any marked evidence of rachitis, 

but was decidedly strumous. 

Pertussis is sometimes complicated by the 
eruptive fevers. There does indeed seem to be 
some affinity between it and measles, so that 
many epidemics of the two have been observed 
at about the same time. During my term of 
service in the New York Foundling Asylum, in 
May, 1878, measles and pertussis prevailed in 
the wards at the same time. Eighteen of the 
children, who were having pertussis, contracted 
measles, and the Sisters, who were very intelli- 
gent and faithful observers, and were requested 
by me to notice the effect of the complication, 
stated that with few exceptions the severity of 
the hooping-cough was increased during the con- 
tinuance of the exanthem. This is contrary to 
the general belief of the effects of intercurrent 
febrile diseases. 

Diagnosis. — During the period of invasion it is impossible to diag- 
nosticate pertussis. Its nature can only be conjectured from a known 
exposure or from the epidemic occurrence of the disease. In the second 
stage, which is characterized by the spasmodic cough, diagnosis is ordi- 
narily easy, and often the parents are able to announce the nature of 
the disease when the physician is called. Still, a mistake is sometimes 
made ; a spasmodic cough very similar to that of pertussis occasionally 
occurs in other maladies. Young infants with bronchitis frequently ex- 
perience great difficulty in the expectoration of mucus, which collects in 
the air-passages and provokes a suffocative cough. The following facts 
will aid in making the diagnosis. Bronchitis, accompanied by a suffo- 
cative cough, is an acute disease, and the cough occurs at an early 
period, usually in the first week. It lacks the inspiratory sound or the 
hoop, and is associated with constantly accelerated respiration and well- 
marked febrile symptoms, dependent on the inflammation. Moreover, 
the cough is occasionally suffocative, according to the amount of mucus 
in the tubes. The spasmodic cough of pertussis, on the other hand, is 
preceded by the stage of invasion, and it occurs only in the second stage, 
when the febrile symptoms have abated. Again, the suffocative cough 
of bronchitis rarely ends in vomiting, which is common in the cough of 
pertussis. 

The only other disease with which there is much likelihood of con- 
founding pertussis is bronchial phthisis. The points of differential diag- 




334 PERTUSSIS. 

nosis are the following: the one epidemic, and spreading by contagion; 
the other non-contagious and isolated : the one embraced in three dis- 
tinct stages, and much shorter; the other chronic, and presenting no 
stages, but commencing with mild non-febrile symptoms, and progres- 
sively becoming more severe : in the one an absence of symptoms in the 
intervals of the cough, provided that there be no complication; in the 
other constant symptoms, such as are common in tubercular disease. 
The previous health, and the presence or absence of a tubercular 
cachexia, should be considered in determining the nature of the disease. 
Usually, in bronchial phthisis, the lungs are also affected, so that auscul- 
tation and percussion may furnish positive proofs of the nature of the 
cough. 

The attacks of suffocative cough, which are produced by the lodgement 
of a foreign body in the larynx, or lower down in the air-passages, bear 
a close resemblance to those of pertussis. The diagnosis can be made 
by the history, for in the one case there is a preliminary catarrhal stage, 
and in the other the cough begins abruptly, and usually after the known 
swallowing of the offending substance, which produces dyspnoea and a 
spasmodic cough as soon as it enters the larynx. The presence of the 
body can also be determined in a large proportion of cases by the laryn- 
goscope and auscultation. 

Prognosis. — A larger proportion doubtless recover under the better 
therapeutics of the present time than in former years. According to 
Hirsch (II., p. 105) 72,900 persons perished from this disease in Eng- 
land and Wales between 1848 and 1855, or one in every forty who 
died ; and Wilde's reports show that it stands fifth as regards mortality 
among the epidemic diseases of Ireland. In New York City during 
the half century ending with 1853, 4840 died of pertussis, or one died 
from this disease in every 76 of deaths from all causes. 

As a rule, the older the child the better the prognosis. Young 
infants may die of suffocation due to the glottic spasm. Eclampsia 
with extreme passive congestion of the encephalon is a not infrequent 
complication in children under the age of five years, and it is apt to 
terminate fatally. It may, however, in my opinion, be averted in most 
cases by proper treatment. In rare instances death may occur in or 
immediately after a paroxysm of coughing, in consequence of rup- 
ture of cerebral or meningeal capillaries, and the effusion of blood, or 
from stasis and coagulation of blood in the venous system, especially if 
convulsions have supervened upon frequent and protracted paroxysms 
of coughing. Other complications, which are likely to arise under con- 
dif&ms which favor their development, and which greatly increase the 
danger and render the prognosis unfavorable, are capillary bronchitis, 
pneumonia, diphtheria, and in the summer season intestinal catarrh. 
In New York I have noticed that pertussis occurring in the summer is 
much more fatal if it become complicated with the intestinal catarrh 
which is an epidemic among infants during that season. 

Feebleness of system and antecedent and accompanying chronic dis- 
ease increase the danger. Pertussis sometimes produces so much 
emaciation and loss of strength, in consequence of the severity and 
frequency of the cough, and the repeated vomiting, that intercurrent 



TREATMENT,. 335 

diseases which in favorable states of the system would probably end in 
recovery, are very apt to prove fatal. 

I usually inform the family that the patient is doing well, if he seem 
entirely well between the paroxysms ; but if he appear ill, whether with 
somnolence, fretfulness, fever, loss of appetite, accelerated breathing, or 
diarrhoea, he is not doing well, and probably has some complication, 
which requires immediate attention. Sudden deaths occur in the second 
stage ; but deaths from causes and conditions which operate in a gradual 
and protracted manner, may occur in the second or third stage. 

Treatment. — In the catarrhal stage the treatment should be the 
same as in mild idiopathic catarrh. Demulcent and gentle expectorant 
measures are required. Care should be taken to employ nothing which 
reduces the strength or impairs the general health. If there be much 
bronchitis with accelerated breathing and frequent cough, mild counter- 
irritation to the chest, and the use of the oil-silk jacket are proper. 

Therapeutic measures are chiefly indicated in the second stage, or 
that of convulsive cough. Proper treatment may control the severity 
of the cough, and abridge the duration of the second stage, and prevent 
or control complications. As with most other diseases whose cause and 
nature are obscure, and which under ordinary circumstances terminate 
favorably, pertussis has received a great variety of treatment. The 
enumeration of the medicines and modes of treatment which have had 
their season of repute, and been employed by intelligent physicians, 
would occupy too much time. The treatment should vary in some 
respects according to the case, but a small number of medicines suf- 
fices, even in the most severe and obstinate forms of the malady. 
Knowledge and appreciation of the pathological state in pertussis assist 
us to the choice of the proper remedies. The specific principle of per- 
tussis produces but little depression of the vital powers. It does not 
impair the appetite by its direct action, or the nutritive function, nor 
does it produce those profound blood changes which we observe in scarlet 
fever and diphtheria. It affects the system injuriously by the severity 
of the cough, the vomitings and consequent loss of nutriment, and the 
complications which frequently occur, some of which involve fatal con- 
sequences. 

Remedies are required which diminish the sensitiveness of the laryngo- 
tracheal surface, which destroy the specific principle in those parts where 
the local manifestations of the disease occur, or control its action — that 
is, in the larynx and trachea. The use of inhalations is at once sug 
gested as most likely to fulfil the indications, since by inhalation ih 
medicine employed is brought into immediate contact with the p 
which are chiefly concerned in the disease. In an extensive epide 
occurring among the large number of children in the N. Y. Foundling" 
Asylum a few years since, after trial of various agents for internal 
treatment, we found that the following mixture seemed to control the 
disease, diminishing the paroxysmal cough, more effectually than the 
other medicines employed : 

R. — Acidi carbolic gss. 

Potas. chic-rat., 

Potas. bromidi 

Glycerinae 

Aquae 



thp 

* 



336 PERTUSSIS. 

To be inhaled from a steam atomizer from three to six minutes every 
two to six hours, according to the severity of the cough. Since this 
time, having frequently treated pertussis, it has seemed to me that car- 
bolic acid is the efficient agent in the above formula, and I now employ 
it in most cases. Carbolic acid appears to have an anaesthetic effect 
on the laryngotracheal surface. It is also an efficient germicide and 
antiseptic agent, so that, if inhaled frequently, it probably destroys the 
specific principle, so far as it resides in the mucus and epithelial cells 
of the air-passages. In my practice it is conveniently employed in the 
croup kettle. Three teaspoonfuls of the saturated solution of carbolic 
acid are placed in water enough to cover the bottom of the croup kettle 
to the depth of two inches, and when this is brought nearly to the boil- 
ing point the vapor is inhaled through the tubes every hour or second 
hour, from three to five minutes. With this treatment infants a few 
weeks old, as well as those of a more advanced age, have, with few ex- 
ceptions, passed through the disease without complications, and with 
paroxysms so mild that the effect of the treatment could not be doubted. 
But the employment of this agent with an alkali is probably preferable. 
Dr. Keating 1 recommends the following formula for inhalation : 

R. — Acidi carbolici cryst gr. iij. 

Sodii biborat., 

Sodii bicarb. ....... aa gr. xx. 

Glycerinse, 

Aquae ........ aa ^j. — Misce. 

An atmosphere loaded with moisture renders the mucus more fluid, 
and the same result may be in a measure produced by the inhalation of 
an alkali, as in the above formula. 

Other antiseptic agents may be equally beneficial with the carbolic 
acid. Some of them, whose odor is not so unpleasant, have been used 
by good observers with alleged benefit, and recommended in the jour- 
nals. Paulet 2 recommends the evaporation, over a suitable fire, of 

R . — Spirits of thymol ....... grammes 10. 

Alcohol " 250. 

Water " 750. 

Keating also recommends the same agent in the following formula : 

R. — Thymol .......... gr. xv. 

Alcoholis g iij. 

Glycerinse . . . . . . . . Iss. 

Aqua? Jxxxiv. — Misce. 

Internal remedies, formerly much used now occupy the second 
place in the therapeutics of pertussis. Belladonna has been largely 
employed, since it appears to diminish the spasmodic element in the 
cough of pertussis. Brown-Sequard, in remarks made before the United 
States Medical Association, in May, 1860, maintained that the dura- 
tion of pertussis, so far as its nervous element is concerned, might be 
abridged to a few days by doses of atropia sufficiently large to cause 
toxical effect; but in one case, which I saw in consultation, in which 
one teaspoonful of tincture of belladonna was given by mistake to a 

1 Medical News, February 28, 1885. 

2 London Medical Kecord, May 15, 1884. 



TREATMENT. 337 

child of about three years, the subsequent cough, though mild, did not 
lose its spasmodic element. Children require a larger proportionate 
dose of belladonna than adults, and it can be safely administered in 
gradually increasing doses until physiological effects are produced, when 
some mitigation in the cough may be expected. Probably the action 
of the drug is on the respiratory centres in the medulla and not directly 
on the muscles of respiration. The effect of belladonna in controlling 
the spasmodic cough is most marked when physiological symptoms are 
produced, and some children require larger doses than others. Thus I 
gradually increased the doses of belladonna to twelve drops for a child 
of three and a half years who had severe pertussis, without producing 
the characteristic efflorescence, while smaller doses from the same bottle 
produced, this effect in older children. Rarely I have discontinued the 
belladonna on account of diminished flow of urine, which this agent may 
or may not have produced, and very rarely on account of suddenly 
developed muscular weakness, which I had reason to think the bella- 
donna caused. This occurred in the case alluded to above, in which 
twelve drops of the tincture were given, so that the muscles seemed flabby, 
and the trunk and head were supported with difficulty. The tincture 
of belladonna is convenient for use, and most of that in the shops is 
active and reliable. The doses which I ordinarily found to be sufficient 
when prescribing belladonna for pertussis and which also produced efflo- 
rescence, were as follows: to a child of two years three drops, and to one 
of six or eight years, eight or ten drops, morning and evening. I 
always, however, commenced Avith a smaller number, and continued to 
administer the dose which produced the local effects alluded to, unless 
the cough were moderated with smaller doses. In the majority of cases 
I have noticed no decided effect till the rash was produced, when the 
symptoms improved, the cough becoming less frequent or less severe. 
By the belladonna treatment the spasmodic stage may not only be ren- 
dered mild, but abridged to two or three weeks. In some cases the 
severe cough begins to yield almost immediately under full closes of this 
agent, but in other cases its continuance for some days is necessary, 
with other remedies as adjuvants, before there is any appreciable benefit 
from its use. 

The use of quinine as a remedy for pertussis was first strongly recom- 
mended by Binz, who embraced the theory of Letzerich, that this disease 
is produced by a fungus, upon which the quinine acts injuriously. I 
have not observed that improvement from the use of this agent, when 
employed alone — and it has been largely prescribed in the institutions 
of New York — which I have observed in cases treated at the same time 
with morning and evening closes of belladonna. Its good effects upon 
the spasmodic cough are probably due to the fact that it diminishes 
reflex irritability (Schlakow and Eulenberg). At the same time it acts 
as a tonic, and improves the appetite, and tends to prevent any depress- 
ing effect which might occur from the belladonna. It is beyond ques- 
tion the proper remedy in the frequent cases in which febrile symptoms 
arise, whether from some complication as bronchitis, pneumonia, or other 
causes. In ordinary cases a child of five years should take about two 
grains four times daily, in the elixir adjuvans or other convenient vehicle. 

22 



338 PERTUSSIS. 

As an antipyretic a larger dose may sometimes be needed. In cases 
attended by marked elevation of temperature antipyrin may be given in 
three grain doses to a child of three to five years every third hour, but 
its depressing and nauseating effects in some instances induce me to 
prefer quinine. 

As the paroxysms are apt to be more severe at night, and the patient 
consequently be deprived of the required sleep, a medicine is indicated 
which will procure some hours of rest, and thereby diminish the number 
of paroxysms. For this purpose the hydrate of chloral is especially 
useful given in doses of two to five grains, according to the age, and 
perhaps repeated. It does not seem to me that chloral exerts any 
marked influence upon the cough; it seems to be useful chiefly in the 
manner stated, namely, by procuring prolonged sleep. 

One of the chief dangers from pertussis we have seen to be the occur- 
rence of great passive congestion of organs, especially of the brain, with 
the liability to hemorrhages, serous effusion, and eclampsia. This is in 
great part prevented by the action of the medicines mentioned above, 
which diminish the severity of the cough, or its frequency. But when 
there are great and frequent congestions of the nervous centres, produc- 
ing eclampsia or premonitions of eclampsia, the use of one of the bromine 
compounds is indicated for its prompt and decided action in averting the 
danger. Even if the symptoms be not urgent, its tranquillizing effect, 
and especially its prompt action in diminishing reflex irritability, render 
it one of the most useful agents in pertussis. If there be sudden twitch- 
ing of the muscles, marked stupor, headache, or fretfulness, or adduction 
of the thumbs across the palms of the hands during the cough, I never 
fail to give the bromide of potassium in sufficiently large and frequent 
doses, and now eclampsia occurs much more rarely in a case which I 
treat from the commencement, than in former years. 

The complications of pertussis require prompt treatment. Whenever 
the child feels ill between the paroxysms, he should be carefully exam- 
ined, and some complication will probably be found which requires 
treatment. If the bronchitis have increased so as to become a compli- 
cation, or pneumonia have arisen, the whole chest should be covered with 
a light flaxseed poultice containing one-sixteenth part of mustard, while 
quinine and ammonia with alcoholic stimulants are given at regular 
intervals. Cerebral accidents are best arrested by. the warm foot-bath, 
cold to the head, and by the bromide and chloral. 

Diphtheria not infrequently supervenes as a complication in a locality 
where it is endemic or epidemic, and if mild it is often overlooked. 
Recently I have seen a case in which diphtheria complicating pertussis 
had continued four days, without being recognized by the attending 
physician, the symptoms being attributed to other causes. The diph- 
theritic patch in these cases appears upon the well-known sore under 
the tongue, in addition to its occurrence upon other parts. The 
secondary form of diphtheria requires the same treatment as the 
primary form. 

Hauke, in 1862, published experiments which showed that both car- 
bonic acid and ammoniacal vapors when inhaled increase the cough, 
while the inhalation of oxygen produced no cough and was agreeable 



PAROTIDITIS. 339 

to the patient. Hence children in close and crowded apartments suffer 
most severely from pertussis, and those who are taken to parks, or the 
country, where vegetation absorbs the carbonic acid, not only obtain 
benefit from the general invigorating influence, but also as regards the 
cough. The fact that fresh and pure air benefits the cough has indeed 
long been known, and has influenced practice, for patients are almost 
universally allowed to be much of the time in the open air, and are 
taken to the parks and upon excursions. Nevertheless caution in this 
regard is required, for exposure in wet weather or to sudden changes of 
temperature is very apt to develop bronchitis or pneumonia. 

Prophylaxis. — Pertussis is very contagious, and it appears to be, 
in nearly all instances, if not in all, contracted by inhaling the breath 
of the patient. I have never observed a case in which it seemed to be 
communicated through a third person, and it is not, I think, usually 
contracted by children living in the same house, if there be no personal 
contact. There is not, therefore, that urgent need of disinfection, and 
of caution on the part of the physician and nurse in their subsequent 
intercourse with healthy children, as in case of the eruptive fevers. 



CHAPTEE II. 

PAROTIDITIS. 

Ordinarily, parotiditis, or parotitis, or mumps, has no premonitory 
stage ; but in exceptional cases languor with fever precedes the disease 
for a few hours. Mumps commences with tenderness in the parotid 
region, followed soon after by tumefaction. The swelling gradually 
increases; it fills the depression under the ear, extends forward and 
upward upon the cheek, and downward to a greater or less extent upon 
the neck. It has been demonstrated in cases of symptomatic parotiditis, 
and the same is probably true of the idiopathic disease or mumps (Vir- 
chow), that the swelling is due to inflammation of the gland-ducts and 
consequent oedema of the interstitial tissue. The inflammation is spe- 
cific, due to a materies morbi in the blood, and hence its decline after 
a fixed period. It reaches its maximum from the third to the sixth 
day. The most prominent point at this time is immediately underneath 
the lobule of the ear. The tumor, which is firm, but slightly elastic, 
presses outward the lobule. In most cases the skin preserves its nor- 
mal appearance over the swelling, but occasionally it presents a faint 
blush. The pressure which movements of the jaw produce on the 
gland renders mastication and even talking painful. Febrile move- 
ment more or less intense occurs, lasting, in ordinary cases, not more 
than forty-eight hours, but occasionally it is more protracted. Vomit- 
ing and epistaxis are sometimes present. The swelling having attained 



340 PAROTIDITIS. 

its maximum size remains stationary a short time, when it begins to 
decline, and by the sixth to tenth day it has entirely subsided. 

In most cases parotiditis is double ; it commences on one side, more 
frequently the left than right, and in from one to four days the oppo- 
site gland is involved. In those exceptional cases in which only one 
parotid is affected, the opposite gland may be the seat of the disease at 
some subsequent period. It has been estimated that the proportion of 
unilateral to double mumps is as one to ten. 

The total duration of parotiditis is usually from eight to ten days ; 
in the mildest cases it may not be more than five days. The submax- 
illary glands are often involved in connection with the parotids, and 
sometimes also the sublingual, although, from their small size and con- 
cealed position, their tumefaction escapes notice. Rarely the tonsils 
are also tumefied. Free perspiration occurs at the commencement of 
convalescence in certain patients. 

The swelling of the parotids sometimes abates suddenly, and in the 
male the testicle, epididymis, and tunica vaginalis become inflamed ; 
while in the female the mammary glands, ovaries, or the labia majora 
are the seat of the so-called metastasis. Occasionally these inflamma- 
tions, which are less frequent in young children than those near the age 
of puberty, when the sexual organs are becoming more developed, 
occur without subsidence of the parotid swelling. They cause consider- 
able increase in the fever and constitutional disturbance, but with proper 
treatment decline in six to eight days, pursuing the same course as the 
parotid inflammation. 

Nature. — Parotiditis is contagious. It is rare in infancy and after 
the middle period of life, occurring chiefly in childhood, youth, and 
early manhood. An incubative period of about twelve days was ascer- 
tained by me in cases under observation in the Protestant Episcopal 
Orphan Asylum of this city. The observations of others give a similar 
result. Parotiditis is a blood disease, having the local manifestation 
described above, and which is our only means of diagnosis. 

Diagnosis. — If the physician has seen but few cases of mumps 
there is danger that he may mistake the swelling for an inflamed cer- 
vical gland, or vice versa, but an inflamed cervical gland presents to 
the finger a hardness almost like that of cartilage, and it is circum- 
scribed or round, and does not invest the ear. These characteristics 
contrast with the elasticity, seat, and shape of the parotid swelling, 
which extends forward on the cheek and surrounds and elevates the 
lobule of the ear. Tumefaction resulting from diphtheritic or any 
other form of fauciai inflammation, or from periostitis affecting the root 
of the posterior molar, may be detected by examining the fauces and 
interior of the mouth. 

Treatment. — This is very simple. Oakum or carded wool may be 
bound over the swelling, and the surface occasionally rubbed with sweet 
oil. Mild laxatives and diaphoretic drinks, such as bitartrate of potas- 
sium or lemonade, are useful. If metastasis occur, the new local affec- 
tion should receive attention. It should be treated in the same manner 
as if it occurred independently of the mumps, while emollient poultices 



TREATMENT. 341 

or fomentations should be applied over the parotids. The ill-effects of 
repellant applications in mumps are shown by the following case : 

On March 19, 1877, I was requested to see a young gentleman of 
eighteen years. He had been well till March 14th, when he complained 
of pain below his ears, and his mother applied a towel, wrung out of cold 
water, around his neck. On the following day slight swelling was 
observed under the angle of the lower jaw, on the right side (submaxillary 
gland), and the cold application was continued. On the 17th the swell- 
ing had disappeared, but the fever and headache had greatly increased, 
so that he was compelled to lie in bed. On the 19th, at my first visit, he 
had such violent headache, and was so intolerant of light and noise, that 
I greatly feared that he had acute encephalitis. All swelling under the 
ears was gone ; the left testicle was tender, and beginning to swell ; 
axillary temperature 102°. The cold cloths were removed from the neck 
and applied to the head, and potass, bromid., gr. xxv, administered every 
third hour. 20th. Axillary temperature 104° ; symptoms unabated and 
alarming. Ordered six leeches to be applied upon the temples and left 
groin, and a purgative, and two drops of the tincture of aconite to be given 
with each dose of the bromide. 21st. Temperature 103°. States that 
numbness and a pricking sensation which he had felt in both legs during 
the last forty-eight hours had ceased (possibly from the aconite). 23d. Is 
convalescent. Has no return of the swelling under the ears, and the 
orchitis has abated. 



SECTION IV. 

OTHER GENERAL DISEASES. 



CHAPTEE I. 

INTERMITTENT FEVER. 

This is a constitutional malady produced by a miasm which emanates 
from the soil. I have notes of 36 cases of this disease occurring under 
the age of 3J years. Several of these patients were treated in pri- 
vate practice, and the rest in institutions with which I have been con- 
nected. In children above the age of 3 J years intermittent fever differs 
but little from that of the adult, while in those under this age it pre- 
sents certain peculiarities. Of the 36 cases which I have observed, 19 
had the quotidian form, 10 the tertian, 2 the tertian becoming after- 
ward quotidian, 1 the quotidian becoming afterward tertian, while in 
the remaining 4 cases ' the form of the disease is not stated. In quo- 
tidian ague the malaria has been supposed to act more powerfully on 
the system, or the system is more susceptible to its influence than in 
the tertian form, and hence the fact that the quotidian is the prevailing 
type of ague in tropical regions, where vegetation is luxuriant, marshes 
extensive, and the heat intense. According to this theory, the feeble 
resisting power in the system of the infant explains the fact that it has 
quotidian more frequently than tertian intermittent, although the latter 
is much more common in the adult in this climate. 

Facts demonstrate that infants sometimes receive intermittent fever 
from their mothers. If mothers during gestation have malarious 
cachexia, their infants, whether born at full time, or, as often happens, 
prematurely, are apt to be small, thin, and feeble, and occasionally 
they have soon after birth distinct paroxysms of the ague. Dr. Stokes 
related the case of a pregnant woman with ague, who believed that she 
noticed periodical tremors of her foetus, but I suspect that she was mis- 
taken as regards the cause, for the paroxysm of intermittent in young 
children is not ordinarily accompanied by tremors. 

The youngest infant in my practice who apparently derived the ague 
from its mother, and probably through the fcetal circulation, had the 
following history : Its mother had occasional attacks of tertian inter- 
mittent during the two years preceding her confinement, and her baby 
when one week old was observed to have the same disease, occurring 
also each second day, the coldness and blueness in the first stage of the 
paroxysm lasting from half an hour to one hour. 
( 342 ) 



SYMPTOMS. 3-±3 

It is not fully ascertained whether a nursing infant may contract 
intermittent fever by lactation, but if it be admitted that it is sometimes 
communicated to the foetus through the maternal circulation, it does 
not seem improbable that the specific principle occasionally enters the 
milk as well as other secretions. I have frequently remarked the pres- 
ence of the disease in nursing infants whose mothers were affected, and 
in one instance, an infant at the breast, whose mother had the ague, 
having contracted it in a suburban village, but was since living- in a 
non-malarious part of the city, presented evident symptoms of the dis- 
ease. Similar observations by Frank, Burdel, and others, do not indeed 
fully prove the communicability of intermittent fever by lactation, but 
render it highly probable. 

The period of incubation in the infant varies greatly, as in the adult. 
When the malaria is concentrated and unusually active, or the con- 
dition of system is favorable for its reception, the disease may commence 
soon after exposure. Thus, in tropical regions, travellers exposed for 
a single night have been known to sicken within twenty-four hours ; 
but in our cooler latitude, a longer incubative period is the rule. In 
the infant, however, in our climate, intermittent fever often begins in a 
very short time after exposure, though there may be an incubative period 
of some weeks. The following have been my observations relating to 
this point : A. M., female, 8 months old, remained two days on Long- 
Island, in October, 1870, and three days after her return to the city a 
quotidian commenced. P. S., male, 11 months old, remained three 
days on Long Island, and a quotidian commenced four days after his 
return. K., 9 months old, remained on Staten Island one week, and 
eleven days after his return a tertian commenced. G. K., aged 3 
years, remained a day and a night on Staten Island in 1870 ; three 
weeks afterward intermittent fever commenced, preceded by a week of 
languor. A. U., female, aged 2 years and 2 months, had the first 
paroxysm of a tertian, two and a half weeks after returning from a visit 
of one week in Hoboken. As there was no malaria in the portions of 
the city where these infants resided, the incubative periods are nearly 
ascertained. 

Whatever may be the nature of the malarial poison, whether a vege- 
table cell, as Prof. Salisbury believes, or something else, it often clings 
tenaciously to the system, and is probably reproduced in it, even under 
circumstances favorable for its elimination. Thus, at one of my clin- 
iques at Bellevue Hospital Medical College in 1871, a child, 10 years 
old, was presented, who had had every year for seven years attacks of 
intermittent fever. The disease was contracted at the age of three 
years in Harlem, and the subsequent residence of the family had been 
in a part of the city where there was no malaria. 

Symptoms. — In infancy, and especially prior to the age of eighteen 
months, the symptoms differ in certain respects from those which char- 
acterize the malady in the adult, and are universally known. In child- 
hood the symptoms are similar to those in the adult, and need not, 
therefore, be described in this connection. 

In the infant the type as we have seen is quotidian, with now and 
then a tertian. Advancing beyond the age of eighteen months, we 



344 INTERMITTENT FEVER. 

meet more and more cases of the tertain type, and in childhood it is 
the common form. I have known the quotidian in the infant, when 
cured, to reappear a few weeks later as a tertian ; but ordinarily it 
remains quotidian, unless the patient have reached the age at which the 
tertian type predominates. 

The paroxysm in the young infant presents three stages, as in the 
adult, but while the second, or febrile, is well marked, the first and 
third are much less pronounced. The patient does not shake (excep- 
tionally, one does even within the first year) in the first stage, but a 
slight tremor may or may not be observed. The countenance presents 
a sunken appearance ; the lips and fingers are livid, while portions of 
the surface not livid are pallid, with the goose-flesh appearance, which 
is, however, less marked than in children of a more advanced age. The 
blood leaves the surface, which consequently shrinks, while it accumu- 
lates in the veins and internal organs ; the pulse is feeble, and readily 
compressed ; the surface grows cool from the diminished supply of blood, 
but the breath is warm, and the internal temperature, so far from being 
reduced, is elevated two or three degrees. The parents may be alarmed 
at the sudden sinking of the vital powers, and seek medical advice, but 
in other instances the first stage is so slight that it passes unperceived, 
till they have been taught to watch for it, and the second stage first 
attracts attention. 

In the second or febrile stage, which immediately succeeds, the pulse 
becomes full and rapid, 120 to 130 or 140 beats per minute, and the 
external as well as internal temperature is elevated as in few other dis- 
eases (104°-108°). The face is flushed, surface dry, and head painful, 
as evinced by the features. This stage lasts about two or three to six 
or eight hours. The third stage, or that of perspiration succeeds, which 
terminates the suffering of the patient till the following paroxysm. In 
infancy the perspiration is not abundant, and in the first half of this 
period is nearly absent. In the interval of the paroxysm the patient 
appears well, except a degree of languor. 

In twenty-four of the cases of infantile intermittent which I have 
treated my notes describe the character of the paroxysms. In sixteen 
of these there was no chill or trembling in the first stage, but blueness 
and coolness of the extremities and features, and sudden prostration. 
This stage lasted from ten minutes to one hour. In .the eight remain- 
ing cases the infants were observed to tremble or shake as in adult cases. 
The perspiration of the third stage was in nearly all cases, when ob- 
served, slight and of short duration, but in some it was not observed. 

During the cold stage, passive congestion of the internal organs occurs 
to a greater or less extent, but the circulation is equalized during the 
reaction of the second stage. The spleen, whose capsule is distensible, 
soon enlarges in many patients, in consequence of the frequent and great 
congestions, constituting the "ague cake.'" This enlargement is more 
common in children than adults. Since my attention has been par- 
ticularly directed to this subject, I have been able to feel the enlarged 
spleen, by examination through the abdominal walls, in probably one- 
third of the cases under the age of ten years. This organ returns to 
the normal size after the ague is cured. From the intimate relation of 



SYMPTOMS. 345 

the spleen to the composition of the blood, it is evident that the char- 
acter of this fluid must be affected if intermittent fever be protracted. 
The blood becomes more and more impoverished, and a state of de- 
cided hydremia supervenes. A few weeks' continuance of the ague 
suffices to produce decided pallor of the features, and surface generally, 
and as all watery blood is prone to transudation, such patients not infre- 
quently present more or less oedema of the face, ankles, and other parts. 
Sometimes, also, especially under unfavorable hygienic circumstances, 
purpuric spots (purpura hemorrhagica) appear under the skin, affording 
additional proof of the change which the blood has undergone. 

In long-continued cases of malarial disease in the adult waxy degen- 
eration of organs is apt to occur, as well as melaneemia. Pigment cells, 
flakes, and particles appear in the blood, the coats of the minute arteries, 
and in various organs, as the spleen, liver, etc. In the child these re- 
sults are more rare. 

Intermittent fever in children, if proper remedial measures are em- 
ployed at an early period, is ordinarily not dangerous, and is quite amen- 
able to treatment ; but that comparatively infrequent and fatal form of 
it, designated the pernicious, occurs more frequently in children than 
adults. In New York City, where the type of malarial diseases is mild, 
I have never met a case of pernicious intermittent in the adult, but I 
can recall to mind such cases in children, two of them fatal. This form 
of the fever occurs in a smaller proportionate number of cases in infancy 
than in childhood, probably because the cold stage is less pronounced. 
In the pernicious ague the system is overpowered — it does not react in 
a degree commensurate with the intensity of the disease. The patient 
enters the cold stage, becomes stupid, and, if not relieved by prompt and 
efficient measures, passes into fatal coma. A type of the disease, there- 
fore, which would not be pernicious in a robust individual, may be such 
in one of a broken-down constitution and feeble reactive power. In 
most cases occurring in children the coma is preceded by eclampsia, 
which is apt to be general and protracted. 

Eclampsia increases the passive congestion of the cerebro-spinal axis 
already present in this stage, and if not speedily relieved may end in 
transudation of serum over the surface of the brain, and perhaps menin- 
geal apoplexy, causing fatal coma. This has occurred twice in my 
practice. 

Sometimes in young children the diagnosis of intermittent fever is 
doubtful, either because the disease has not continued sufficiently long, 
or there has not been the characteristic paroxysm. The patient may 
be feverish, and fretful, with anorexia, and evidences of headache, but 
without the usual distinctive symptoms. I have sometimes in such 
cases been able to establish the diagnosis by detecting enlargement of 
the spleen. In examining for the "ague cake," the child must lie 
quietly on its back, and the fingers, placed midway between the epigas- 
trium and umbilicus, be carried gently but with firm pressure outward 
in the direction of the spleen, when the anterior edge of this organ will 
be felt, if it be enlarged. It is impossible to make the examination 
when the child cries, on account of the contraction of the abdominal 
muscles. 



346 INTERMITTENT FEVER. 

Treatment. — It is evident that no time should be lost in applying 
appropriate remedies in a case of infantile ague ; for, although the first 
paroxysm may be mild, the next may be more severe, and attended by 
danger. Moreover, the sooner the disease is cured, the less liable it 
seems to be to return. Therefore we prescribe at once the sulphate of 
quinia or cinchona, one and a half grains of the latter producing the 
effect of about one gTain of the former. Our experience in the children's 
class in the Outdoor Department has been chiefly with the sulphate of 
cinchona, on account of its cheapness, and there has yet been no case 
of ague which it has failed to control. A recent writer has published 
statistics showing his success in curing intermittent fever by this agent, 
but nothing in therapeutics is more easy than to cure this disease in our 
climate by either of the sulphates mentioned. The chief difficulty con- 
sists in preventing a return. To an infant of two years I prescribe one 
grain of sulphate of quinia, or the equivalent of sulphate of cinchona, 
three times daily, till all symptoms of the ague have disappeared; then 
tAvice a day during the subsequent week, and afterward once a day for 
some days; and finally twice or thrice a week. It is only by the pro- 
tracted use of the drug in occasional doses that the return of the inter- 
mittent can be prevented. 

It is important in administering these sulphates to infants to employ 
a vehicle which will, so far as possible, disguise the bitterness. The 
vehicle which I prefer for their administration is the elixir adjuvans or 
elixir tarax. co. The following formula is for a child of three years : 

R. — Quinise sulphat. .... . . gr. xij. 

Syr. pruni virginiani ..... ^jss. — Misce. 

The following is also a good formula: 

R. — Quiniae sulphat gr. xvi. 

Ext. glycyrrhizse . . . . . . sji. 

Syr. rubi. idsei., (Raspberry) .... §ij. — Misce. 

One teaspoonful three to five times daily. The first dose should be 
given immediately after the fever abates. In this climate two or three 
days suffice to cure the disease, after which by daily but gradually dim- 
inished use of medicine in the manner stated above, the return of the 
malady is prevented. Protracted cases attended by anaemia require the 
use of iron in addition to the remedy which is designed to control the 
disease. 



REMITTENT FEVER. 347 



CHAPTEE II. 

KEMITTENT FEVEK. 

If a physician was to consult the standard treatises on diseases of 
children in order to ascertain the nature of intermittent fever, he would 
rise from the perusal with no clear idea of it. One tells us that the 
remittent fever of children is identical with typhoid fever of adults; 
another, that it is a gastro-intestinal inflammation ; and, finally, Hillier 
believes that there is properly no such disease, and that the term should 
be dropped from the nosology of diseases of children. There is, how- 
ever, a remittent fever of children as well as adults, and much of the 
confusion which exists in reference to it arises from the fact that writers 
have not kept in view what constitutes a fever. 

Febrile action which has a local cause is not an essential fever, and should 
not be described as such. It happens that in children a symptomatic 
remittent fever arises from a variety of local causes, as dentition, intes- 
tinal worms, subacute gastro-intestinal inflammation, etc. But all such 
cases should be excluded from our consideration of remittent fever, as 
clearly as we distinguish the continued fever of pneumonia or bronchitis 
from that of typhus or typhoid. 

There is an essential remittent fever of children due to malaria. The 
same conditions which produce intermittent fever do, in a certain pro- 
portion of cases, produce a fever which does not intermit, but continues 
with more or less pronounced exacerbations a certain number of days, 
when it ceases or becomes intermittent. Those who practise in mala- 
rious localities notice a larger proportion of cases of remittent fever 
among children than adults, because their constitutions are less able to 
resist the malarial poison, so that an exposure which in an adult would 
produce milder disease, namely, a tertian ague, frequently causes a quo- 
tidian or remittent in the child. In young and feeble infants the pro- 
portionate number who have remittent fever is large. Cases, too, are 
not infrequent in localities not malarious, of a remittent fever occurring 
more frequently in the spring and autumn than in other seasons. Some 
of these cases are perhaps a mild type of typhus or typhoid fever, but 
in other instances the conditions do not appear to be present which ordi- 
narily give rise to that disease, and they do not occur in connection 
with cases of typhus or typhoid in adults. The cause, though obscure, 
is apparently atmospheric. 

The symptoms of remitttent fever vary in different cases. The 
exacerbations and remissions are more pronounced in some than others. 
Even in those cases in which the fever is due to paludal emanations, 
and occurs in connection with cases of the intermittent, the febrile 
movement may be almost uniform, slight exacerbations occurring in 
the latter part of the day. In other cases the exacerbations and remis- 
sions are pronounced, the febrile excitement abating in a perspiration. 



348 TYPHOID FEVER. 

Occasionally the fever is higher on each second day. Cephalalgia is 
common, and in severe cases delirium and stupor are not infrequent. 
There may be distinct remissions in the beginning, and afterward, for 
a few days, the fever be pretty uniform, when it again remits or ceases. 
The tongue is covered with a light fur. Thirst, loss of appetite, a 
tendency to constipation, scanty and high-colored urine, containing 
perhaps urates, and a cough due to mild bronchitis, are common 
symptoms. 

When remittent fever is due to marsh emanations, the same ana- 
tomical characters are doubtless present as in the adult, namely, blood 
containing more or less pigmentary matter, enlargement of the spleen, 
bronzing of the spleen, and, in some cases, of the liver, and sometimes 
of the brain. 

The diagnosis is not always easy. On the one hand, local dis- 
eases with symptomatic remittent fever are to be excluded, and, on the 
other, typhus and typhoid. The discrimination of it from typhus and 
typhoid fevers is practically of little moment, but it is a matter of vital 
importance to make a differential diagnosis between it and the local dis- 
eases. I have known one of the acutest diagnosticians and most emi- 
nent physicians of New York mistake incipient meningitis for it, a 
mistake indeed not uncommon. The points involved in differential 
diagnosis will be considered in our description of the local disease. 

Treatment. — If we have ascertained by a careful examination that 
the fever is remittent, and -not symptomatic, but essential, there is one 
remedy which is required in nearly all cases, namely, quinia, or its 
equivalent, cinchona. Mild febrifuge medicines, with light diet, may 
be first employed in sthenic cases, in which the pulse is full and strong, 
and the quinia given when the fever has somewhat abated. The diet 
should be bland, but nutritious, and the bowels be kept regularly open 
by citrate of magnesium or other mild aperient. Bromide of potassium 
or hydrate of chloral may be occasionally employed, as recommended in 
the treatment of typhoid fever, to produce quietude or sleep, in cases 
attended by delirium or insomnia. A warm mustard foot-bath and cool 
applications to the head are useful in such cases. 



CHAPTER III. 

TYPHOID FEVER. 

Typhus and typhoid fevers occur in children, but the former is mild 
and infrequent, rarely occurring except when adults of the same house- 
hold are affected. It requires little treatment, besides good nursing. 
Typhoid fever, on the other hand, is not infrequent in children, and, 
as it presents certain peculiarities prior to the age of puberty, it is 



CAUSES. 349 

proper to describe it in this connection. This disease is much less 
common in infancy than in childhood, and in the first half of infancy 
is believed to be rare. Still, there can be no doubt that many cases in 
the first years of life are not diagnosticated, being mistaken for subacute 
and protracted entero-colitis. It is probably more common under the 
age of six years than is usually supposed, although the younger the 
child beloAV this age the less frequent does it appear to be ; while above 
the age of six years it is more and more frequent until puberty. In 
the statistics of Cadet de Gassicourt, embracing 276 children, 3 were at 
the age of two years, 7 at the age of three years, 8 at four years, 13 at 
•five years, and the number gradually increased in successive years until 
there were 32, 41, and 42 cases at the ages of twelve, thirteen, and four- 
teen years. 

Causes. — It is now generally admitted that typhoid fever is mildly 
contagious, and that its specific principle abounds largely in the dejec- 
tions and excretions of the patient. It is uncertain, whether it is com- 
municable by the breath of the patient, or exhalations from his surface. 
If it is, it is slightly so, while numerous observations demonstrate its 
communicability through the use of night-stools or privies which contain 
the evacuations. 

Many cases are on record, in which typhoid fever was contracted 
from drinking water which was polluted through drainage by the stools 
of typhoid patients. Epidemics of considerable extent and severity have 
been traced to this cause. This disease occurs more frequently in the 
autumnal than in the other months. Observations show that typhoid 
epidemics are most frequent and severe after protracted hot weather, 
attended by a scanty rainfall, and diminished water- supply. The most 
extensive epidemic which I have observed in New York City, affecting 
largely children, occurred after the protracted hot weather of 1882, in 
which there was great scarcity of Croton water, and the proper flushing 
out of the waste pipes therefore impracticable. To the noxious effluvia 
engendered in the tenement houses under such conditions the prevalence 
of the fever seemed to be largely attributable. 

It is an interesting fact that typhoid fever is rarely contracted directly 
from a patient provided that his stools and soiled linen are promptly 
disinfected and removed. The virulence of the poison contained in the 
stools appears to increase after their evacuation ; hence the great viru- 
lence which they acquire hours after they have been removed from the 
sick room, and have contaminated the drinking-water. 

There is little doubt also that typhoid fever originates de novo, 
caused by the miasm produced by decaying animal or vegetable matter. 
Numerous cases have been observed in which it originated from defec- 
tive sewerage, or decaying vegetables in cellars, in localities in which 
no case had previously been observed. The germs of the disease when 
it originates under such circumstances may probably be received into 
the system by inspiration and in the ingesta. The use of well-water 
which is contaminated with sewer drainage has been repeatedly known 
to produce it. It has even been traced to impure w r ater used in rinsing 
milk-cans which contaminated the milk, and to impure ice which con- 
tained the subtle specific principle. Boys are more frequently attacked 



350 TYPHOID FEVER. 

than girls ; according to some statistics, in the proportion of three to 
one. Deterioration of the health from general causes increases the lia- 
bility to be attacked. On the other hand, those having tuberculosis, 
carcinoma, heart disease, and probably certain other visceral lesions, 
are more apt to escape than those in health. 

Klebs believes that he has discovered the specific principle of typhoid 
fever in a microorganism which he designates the bacillus typhosus. It 
occurs in the form of little rods, each containing a spore at the centre 
and often one at the end, which spores form new bacilli. He believes 
that the bacilli enter the system both by the respiratory passages and 
alimentary canal. 1 He found numerous bacilli of this kind in Peyer's 
patches. Eberth has also found rod bacteria in the intestinal mucous 
membrane, mesenteric glands, and spleen in typhoid fever, which 
appear to vary from other rod bacteria by a difference in staining. In 
seventeen cases these bacilli were found in six, and not found in eleven. 2 
"YVernich, on the other hand, believes that the rod bacteria of Klebs 
and Eberth are the bacteria subtilis common in the large intestine, 

O 7 

which have undergone further development, acquired new properties, 
and perhaps have become the cause of disease. 3 It is evident that it 
is still very uncertain whether the specific principle of typhoid fever has 
been discovered. The test of cultivation, and the propagation of the 
disease from the cultivated microbe, are lacking. 

Anatomical Characters. — Since typhoid fever is a constitutional dis- 
ease, we would expect to find early and important changes in the blood. 
No alteration, however, has been discovered in this fluid peculiar to 
typhoid fever. The amount of fibrin is diminished as in most of the 
essential fevers, and its coagulation is feeble, forming, when the blood 
stands, soft, small, and dark clots. When the fever has continued for 
some time, a state of anaemia more or less decided supervenes, in which 
the amount of albumen and blood-corpuscles is diminished. Although 
there are often decided symptoms referable to the nervous system, no 
constant changes have been discovered in the brain or spinal cord. The 
changes observed in them when death has occurred in the course of 
typhoid fever have been for the most part due to other causes. It is 
different with the respiratory system. After the first week of typhoid 
fever bronchitis is almost as constant as inflammation of the fauces in 
scarlet fever, and accordingly we find in fatal cases redness and thick- 
ening of the bronchial mucous membrane, which is covered w T ith a viscid 
and ordinarily scanty secretion. Hypostatic congestion of the lungs, 
with more or less oedema, and in severe and enfeebled cases hypostatic 
pneumonia, are not uncommon. In the bronchitis and state of feeble- 
ness we have the causes of pulmonary collapse, and this lesion is not 
infrequent over limited portions of the lungs, especially if the bronchitis 
affect the smaller tubes. 

The lesions occurring in the digestive system are important. The 
mucous membrane of the small intestine is more or less injected, and at 
an early period, even by the second or third day, the patches of Peyer, 
solitary glands, and at the same time the mesenteric, begin to enlarge. 

1 Phil. Med. Times, Dec. 3, 1881. 2 British Med Jour., Nov. 26, 1881. 

3 See article on Typhoid Fever, System of Practical Medicine, 1885, Lea Bros. 



SYMPTOMS. 351 

It has been stated by high authorities that the enlargement is due to 
infiltration with a peculiar substance, which has been termed the typhus 
material. I have made microscopic examination of these glands in 
typhoid fever of the adult, and have found a considerable increase of the 
small round granular cells of which they are composed. I do not, there- 
fore, doubt that the enlargement is due mainly to hyperplasia of the 
cellular elements of the glands, though there is probably infiltration to 
a certain extent of inflammatory products between the cells. The 
mucous membrane over the glands undergoes inflammatory thickening 
and softening. In the adult, sloughing of this membrane is frequent, 
with the disintegration of the glands and their elimination into the in- 
testines, producing ulcers, small and circular, corresponding with the 
site of the solitary glands, large and oval or irregular, corresponding 
with the site of the agminate. Disintegration of these glands and the 
formation of ulcers are less frequent in children than in adults. In the 
adult who recovers, the mesenteric glands, and those of the solitary and 
agminate which are not destroyed, return to their normal state by fatty 
degeneration, liquefaction, and absorption of the redundant cells. In 
the child this is the common result, instead of sloughing and disintegra- 
tion, as regards both the solitary and agminate glands, and uniform 
result as regards the mesenteric, and I may add bronchial glands, which 
are also in a state of hyperplasia. The absence of ulceration or its 
slight extent affords explanation of the fact that intestinal perforation is 
very rare in children. 

The spleen gradually enlarges, often to twice the normal size, has a 
dark red color, and is softened. Enlargement of the spleen possesses 
great diagnostic value in those cases in which the diagnosis is obscure. 
For while very similar intestinal lesions may occur in chronic entero- 
colitis, the coexistence of these lesions with the splenic enlargement and 
softening shows the constitutional nature of the malady. 

In cases which are severe, and which present a decidedly adynamic 
type, the muscles become soft and flabby, the action of the heart is 
feeble, and more or less passive congestion of the viscera results. In 
such cases congestion of the kidneys and albuminuria are not infrequent. 

Incubative Period. — As in scarlet fever and diphtheria, the incubative 
period in typhoid fever varies. In three cases detailed by Griesinger, 
the fever began twenty-four hours after exposure. In a school at Clap- 
ham twenty out of twenty-two boys sickened, according to Murchison, 
within four days after exposure. Authenticated cases of a longer incu- 
bative period are on record, so that Murchison believed that it is com- 
monly about two weeks, and William Budd that it is in most instances 
from ten to fourteen days, but cases have occurred in which it seemed 
to be as long as twenty-eight days. 1 

Symptoms. — Typhoid fever has a prodromic stage of a few days, 
sometimes of a week or more, in which the child appears languid, indis- 
posed to play, and has little appetite, but complains of no pain unless 
occasional slight headache, and has no symptom which would lead the 
friends or even physicians to suspect the grave nature of the disease 
which impended. By and by a slight fever occurs. 

1 See article Typhoid Fever, System of Practical Medicine, 1885, Lea Bros. 



352 TYPHOID FEVER. 

In exceptional instances typhoid fever begins with a chill followed by 
pronounced fever. It occurred in three of the fourteen cases observed 
by Prof. Jacobi, in Bellevue Hospital. This was a larger proportion of 
cases with such commencement than I observed in the epidemic of 1882 
or have since observed, but the cases in Bellevue seem to have been 
unusually severe, since five of the fourteen died. 

The febrile movement, which gradually becomes more pronounced, 
remits, but does not cease in the morning, and has evening exacerba- 
tions. After the first week of fever the remissions are less marked, but 
the fever is not uniform at any period in its course. Hence some of 
our ablest writers on diseases of children continue to designate typhoid 
fever of children remittent fever, fully aware of its identity with typhoid 
fever of the adult. As the case advances, the appetite fails, all solid 
food being refused, and liquid food being taken more from thirst than 
hunger. The tongue in the first week, and in some patients throughout 
the course of the disease, is covered with a light moist fur, while in 
others having a graver type of the fever the tongue after the first week 
is dry and brown. During the prodromic period, and in the first week, 
the bowels act regularly, or are slightly relaxed, and they are readily 
affected by purgative medicines. After the first week there is in most 
children a tendency to diarrhoea, which requires now and then the use 
of astringent's, the stools being watery and brown, or dark yellow. The 
abdominal walls are seldom retracted, but prominent, especially after 
the first week, in consequence of meteorism, which is present in children 
as well as adults. Sometimes there is apparent tenderness, when pres- 
sure is made over the right iliac region, but this must not be confounded 
with hyperesthesia, which is common in the commencement of febrile 
diseases in children, and which is observed especially upon the abdomen, 
chest, and inner part of the thighs. 

The respiration in the first week is slightly accelerated, as it is in all 
febrile diseases. In the second week, and subsequently when bron- 
chitis is developed, the respiration is ordinarily more accelerated, though 
not in a marked degree, unless in those exceptional instances in which 
there is an abundant collection of mucus in the smaller bronchial tubes. 
A cough is often present, dependent on the bronchitis, and varying in 
character according to the degree and stage of the inflammation. In 
the first days of the fever it is infrequent, or lacking ; at a later stage 
it is more frequent, and not so dry, though in cases of ordinary severity 
the amount of expectoration is inconsiderable. Hypostatic congestion, 
oedema, hypostatic pneumonia, splenization, or thickening of the alveolar 
walls, and collapse, which may, and some of which not infrequently do 
occur in the advanced disease, increase, more or less, the frequency of 
the respiration and the cough, and modify the physical signs. 

The pulse in the first week, in ordinary cases, is from 100 to 110 or 
115. It gradually becomes more accelerated, numbering in the second 
week 123 or more; in grave cases even 160. The more frequent 
the pulse, the greater the danger and more unfavorable the prognosis. 
During the exacerbations the number of pulsations per minute is 15 or 
20 more than in the remissions. The change in temperature corre- 
sponds with that of the pulse, being from 1° to 2° higher in the ex- 



COMPLICATIONS. 353 

acerbation than remission. The extremes of temperature in cases of 
ordinary severity, are about 101° to 104°. A temperature above 105° 
shows a grave, probably a fatal type of the disease, or else a serious 
complication. 

There is great variation as regards the symptoms referable to the 
nervous system. Headache is common in the prodromic and initial 
stages, after which it ceases. A few are delirious even from an early 
period, screaming loudly, or muttering incoherently, but the majority 
are quiet, having, indeed, a degree of mental dulness, but being able to 
appreciate questions when aroused, and answering correctly. Subsultus 
tendinum and carphologia, which some exhibit, show that there is pro- 
found disturbance of the nervous system. Epistaxis occurs occasionally 
in the first week, as in the adult, but is not abundant. 

The rose-colored eruption appears in children as well as adults between 
the sixth and twelfth days, but is more frequently absent in the former 
than the later ; sometimes the number of spots is less than half a dozen. 
Sudamina are common in the second and third weeks, and perspirations 
may occur at any time in the course of the fever, but without ameliora- 
tion of symptoms. More or less deafness is common, being in most 
instances a purely nervous symptom, without, therefore, any structural 
change in the ear, but it is possible, as has been suggested by certain 
writers, that it sometimes results from inflammatory thickening of the 
Eustachian tube or external meatus, or from a weakened and flabby 
state of the muscles of the ear. 

The duration of typhoid fever is not uniform ; while mild cases may 
end in two weeks, those of a severer type continue three or even four. 
The patient becomes progressively more emaciated and feeble. In pro- 
tracted and severe cases his condition seems very unpromising to one 
not familiar with the clinical history of the fever. Pale, emaciated, and 
feeble, probably passing his evacuations in bed, taking little notice of 
objects around him, he presents, at the close of the third week, an 
appearance of helplessness, notwithstanding the best of nursing, and 
the constant employment of sustaining measures, which is truly dis- 
couraging;. 

Complications. — The chief complications of typhoid fever are 
broncho-pneumonia, already sufficiently described, enteritis, intestinal 
hemorrhage, peritonitis, otitis, parotiditis, and muguet. In one in- 
stance I lost a patient about ten years old, in whom the fever had 
nearly terminated, by the sudden accession of croup. There is, as we 
have seen, in ordinary cases, more or less inflammation of the mucous 
membrane of the air-passages, and of the intestines, especially, in the 
vicinity of the patches of Peyer. It is easy to understand how, under 
circumstances which may arise in the fever favorable to the develop- 
ment of mucous inflammations, the bronchitis and enteritis may so 
increase as to constitute complications. They are the most frequent of 
the serious complications. 

Feeble action of the heart, common in severe cases of typhoid fever, 
and which after the second week is partly attributable to granulo-fatty 
degeneration of the muscular fibres of the heart, which is frequent in 
grave forms of the infectious diseases, obviously favors the occurrence 

23 



354 TYPHOID FEVER. 

of bronchial and pulmonary congestion. Hence the proneness in these 
cases of the inflammation to extend downward from the larger to the 
smaller bronchial tubes and to the lungs, so that broncho-pneumonia 
becomes an occasional very grave complication. 

In the child as well as adult with this disease, the mucous membrane 
of the lower part of the ileum in the vicinity of Peyer's patches is 
frequently thickened and hyperaemic, a true intestinal catarrh. AVe 
can readily understand how under certain circumstances this may 
become aggravated, so as to constitute an intestinal inflammation of 
considerable extent and gravity, a severe entero-colitis, so that the local 
symptoms predominate over the constitutional and aggravate the later. 

In the adult, as is well known, the Peyerian and solitary glands 
becoming more and more prominent by proliferation of the cellular 
elements (the lymphoid cells), begin to ulcerate in the second week, and 
slough in the third, forming the typhoid ulcer, which is slow in healing, 
and aids in keeping up the diarrhoeal state. Such destructive or 
necrotic inflammation is rare in young children, but it may occur in 
those of a more advanced age. 

Intestinal hemorrhage is therefore an occasional accident. Hillier 
met four cases in thirty of the fever. It indicates the presence of ulcers 
upon the surface of the intestines. The younger the child, the less the 
liability to it. Some, in whom it has occurred, recover, but others die. 

Intestinal perforation is more rare in children than in adults, as might 
be inferred from the statement already made, that intestinal ulceration is 
less frequent and extensive in them. Statistics show that perforation 
occurs only once in 232 cases. Therefore, as perforation is the com- 
mon cause of peritonitis in this disease, this inflammation is a rare 
complication. Peritonitis may, however, occur in typhoid fever with- 
out perforation. In one such case (an adult) in the fever wards attached 
to Charity Hospital, local peritonitis with fibrinous exudation occurred 
opposite two ulcerated patches of Peyer, the ulcers extending nearly to 
the peritoneum, but not perforating. The lesions observed in this case 
throw light on those cases of peritonitis complicating typhoid fever 
which recover, the cause of which has received a different explanation. 

In advanced and greatly debilitated cases, thrush sometimes appears 
in the interior of the mouth, and upon the fauces. It is always an 
unfavorable prognostic symptom in children suffering from chronic or 
protracted disease. Parotiditis is also a rare complication. Otitis, 
commencing with pain, and producing a discharge which may continue 
for weeks, is not rare, though less frequent than in scarlet fever. The 
otitis is commonly external, but it may, in scrofulous subjects, extend 
to the middle ear. 

Diagnosis. — This is more difficult in children than in adults, and 
the younger the child the greater the difficulty. In infants protracted 
entero-colitis, with febrile action and dry furred tongue, cannot in cer- 
tain cases be positively diagnosticated from typhoid fever by the symp- 
toms and clinical history. Typhoid fever is believed, however, to be 
rare at this age, for an infant nourished at the breast, and rarely drink- 
ing from a cup, is very seldom exposed to the cause of the disease. 
When, however, as now and then happens, a young child presents the 



DURATION 355 

symptoms characteristic of protracted subacute entero-colitis, or typhoid 
fever, and older members of the household have the fever, it is highly 
probable that the case is one of the latter disease, and it should be 
treated accordingly. 

Even in older children typhoid fever is frequently mistaken for simple 
subacute enteritis, or entero-colitis, or vice versa. The following facts 
aid in the differential diagnosis. In typhoid fever there is total loss of 
appetite, while in the subacute intestinal inflammation food is not 
entirely refused. Diarrhoea commences early in the inflammation, 
while in the fever it is not ordinarily till after the lapse of a few clays. 
Abdominal tenderness in the fever is not appreciable, or is located in 
the right iliac region ; in the other disease it is general over the abdo- 
men, or located in the umbilical region. In typhoid fever there is 
bronchitis with a cough which is absent in the inflammation. In 
typhoid fever there are certain other symptoms, more or fewer of which 
are present in most cases, and which do not occur in the intestinal 
diseases, except as a coincidence; for example, headache, epistaxis, 
stupor, delirium, and perhaps the rose-colored spots. 

Typhoid fever may be mistaken for meningitis, during the first week, 
but in meningitis there is more constipation, irritability of stomach, and 
less elevation of temperature. Moreover, in meningitis, at a compara- 
tively early stage, we are able to detect patches of congestion of the 
features coming and disappearing suddenly ; and slight inequality of 
the pupils, or their oscillation when the light is uniform ; signs w T hich 
are lacking in typhoid fever. In a doubtful case the ophthalmoscope 
might be employed, which in meningitis discloses congestion of the 
vessels of the retina, oedema, etc., anatomical changes which do not 
pertain to typhoid fever. 

The differential diagnosis of typhoid fever and acute tuberculosis 
may be made by attention to the following points. In tuberculosis 
there is cough, with some acceleration of respiration from the first, 
without epistaxis, stupor, or other nervous symptoms, and without the 
abdominal symptoms which are so prominent in the fever. 

Duration. — The duration of typhoid fever varies from one to about 
five weeks, but complications which may arise may protract the febrile 
movement. Henoch states that in eighty cases which came under his 
observation, the duration in 7 was from 7 to 9 days, in 30 from 10 to 13 
days, in 31 from 15 to 23 days, in 7 from 23 to 35 days, and in 5 
from 35 to 49 days. Recovery from a severe and protracted attack is 
slow, several weeks or even months elapsing before complete resto- 
ration to health. A tendency to diarrhoea often continues several 
weeks after the fever proper ceases, necessitating a rigid oversight of 
the diet, and the occasional employment of astringents. The milder 
the attack of typhoid fever, the less, as a rule, are the intestinal lesions, 
and since ulcerations of Peyer's patches are absent or slight in children, 
there is little danger from this source in them. In the adult, on the' 
other hand, the intestinal disease constitutes one of the chief sources of 
danger, and it renders convalescence uncertain and protracted. Henoch 
states that of 137 cases of typhoid fever in children he lost only 16. 



356 TYPHOID FEVER. 

Prognosis. — A much larger percentage of children recover than of 
adults. Although there be great emaciation with loss of strength 
recovery may be confidently predicted, provided that no serious com- 
plication occur. In fatal cases which I have met, the unfavorable 
result occurred, as a rule, from the complications, rather than directly 
from the malady. The condition in which severe typhoid fever leaves 
a patient is favorable for the development of tubercles, and now and then 
they occur, disappointing our expectations and prediction of recovery. 

Treatment. — Typhoid fever, like typhus, cannot be abridged by 
treatment, and the indication is to sustain the vital powers, diminish 
the intensity of the febrile movement, and to control any untoward 
symptom or complication. Quinia, so useful in malarial diseases, may 
be administered in small doses for its tonic effect, and as an aid in pro- 
moting digestion. It is commonly and properly prescribed in some 
convenient vehicle for this purpose, but it does not antagonize the 
typhoid, as it does the malarial poison. Perturbating medicines, and 
especially cathartics, should be given with caution. The tendency to 
intestinal ulceration and hemorrhage, and the anaemic nature of the 
fever, require abstinence from or cautious use of such agents. A tem- 
perature remaining under 103° usually involves little danger. If it 
rise above that, antipyretic measures should be employed. The use of 
salicylate of sodium, large doses of quinine, and cold-water ablutions, 
are the three admissible remedies for this state. The salicylate I sus- 
pect impairs the appetite, and retards digestion, and the quinine is much 
less efficient as an antipyretic in this fever than cold-water bathing. I 
therefore order the nurse to bathe frequently the forehead, face, hands, 
arms, neck, and sometimes the chest, with cold water, to which it is 
proper to add alcohol or some spirituous lotion. A cloth wrung out of 
ice water or an ice bag should be applied over the head, and the hands 
may be allowed to lie a considerable time in a wash-bowl containing the 
lotion, which is always grateful to the patient. The water treatment 
thus applied will usually reduce the temperature one, two, or three 
degrees within a few hours. 

In all cases of typhoid, as in other essential fevers, free ventilation is 
required from an open window, and the bedding and body linen should 
be changed every day. 

Observations made during the last dozen years appear to show that 
the mineral acids have a salutary effect upon the course of the fever. 

The dilute nitric, muriatic, or nitro-muriatic acid should be given 
largely diluted with water, and, if possible, through a glass tube so as to 
protect the teeth. I have recently administered the dilute muriatic acid 
in the acidulated liquid pepsin prepared by Mr. Kress, of Fifty-second 
Street and Broadway, in the treatment of typhoid fever. One ounce 
of the liquid contains 30 min. of the dilute acid, and one teaspoonful 
can be given every third hour to a patient of five years. The scanty 
secretion of gastric juices in this disease, the poor appetite and slow 
digestion, indicate the need of such medicine, and thus far the result has 
been good. A 

If the pulse be rapid and weak, or fluctuating, digitalis meets the 
special indication, and it can be administered with or between the doses 



TREATMENT. 357 

of quinine. As there is great proneness to diarrhoea and intestinal 
ulceration, the selection of the proper diet is important, and of all the 
dietetic articles milk is the one upon which we must chiefly rely for the 
sustenance of the patient. While it contains the desired nutriment it 
is easy of digestion, and possesses, when fresh and of good quality, no 
irritating property which would aggravate the intestinal disease. The 
meat broths or juices, fresh eggs beaten up in milk, farinaceous foods, as 
barley, wheat, or rice flour in the milk, are proper adjuvants to the milk 
diet. The dry state of the mouth, and scanty secretion of saliva, and 
probably also of the pancreatic juice by which starch is digested, show, 
however, that only a moderate amount of farinaceous food can be assim- 
ilated during the fever. The patient may be allowed to drink cold 
water in moderate quantity. 

Mild cases of typhoid fever do not require alcoholic stimulants, but 
they are useful in severe cases in the form of wine whey or milk punch, 
especially in the third and fourth weeks, and during convalescence. 
When the pulse is feeble and quick, the mind wandering, and the fingers 
tremulous, the regular and judicious use of alcohol aids materially in 
sustaining the vital powers during the critical period. 

The complications which may arise in the course of the fever require 
prompt treatment. For diarrhoea opium and bismuth are needed; for 
intestinal hemorrhage an ice bag over the right iliac region, and intern- 
ally opium with acetate of lead, or with a large dose of subnitrate of 
bismuth, cr small and repeated doses of turpentine. A one-grain ergotine 
pill every fourth hour to a child of eight years, also aids in arresting 
the hemorrhage. But intestinal hemorrhage as a result of typhoid 
ulcerations is much more rare in children than in adults. Bronchitis 
and pneumonia require mildly irritating poultices, with the oil-silk 
jacket. 

Typhoid fever may relapse, but the second attack is commonly milder 
than the first. Nevertheless on account of the liability to its return, 
the patient should be quiet and free from perturbating influences during 
convalescence. 

To guard against the spread of the disease, the stools should always 
be promptly disinfected, by adding to the night-stool carbolic acid and 
a solution of the sulphate of iron, or a solution of the chlorides, and all 
soiled linen should be placed in boiling water. 



358 CEREBROSPINAL FEVER. 



CHAPTEE IV. 

CEREBROSPINAL FEVER. 

Several years ago, before New York physicians had any personal 
experience with cerebro-spinal fever, an outbreak of it of moderate 
extent occurred at or near Long Branch, and from its proximity, 
physicians were apprehensive that it might enter New York. Very 
interesting discussions consequently took place in the Academy of Medi- 
cine concerning the cause and nature of this malady, and theories crude 
and unfounded, in consequence of inexperience, were then expressed. 
Unfortunately the fears of physicians who participated in that discus- 
sion have been realized. The disease entered this city in the autumn 
of 1871, appearing first among the horses of the large stables of the 
stage and car lines, disabling and destroying many of them. In 
December, 1871, it commenced among the people, and since that time 
it has not been absent from the city. Its unknown cause, which in 
country towns soon dies out or becomes inoperative, from lack of the 
conditions which sustain and perpetuate it, finds in this great assem- 
blage of people, and in the state of the streets and domiciles, the 
conditions favorable for its development and sustenance, so that cerebro- 
spinal fever is now fully established with us. It has become one of the 
scourges of childhood, destroying many lives each year, and injuring 
irreparably, by deafness or in other ways, many who recover. We are 
now much better prepared, by sad experience, to discuss this disease 
than w T ere those physicians who participated in the debates alluded to 
above. 

Etiology. — It is not improbable, from the clinical history of cerebro- 
spinal fever, and from recent discoveries touching the parasitic origin 
of several of the common constitutional maladies, that the obscure and 
mysterious cause of cerebro-spinal fever will yet be discovered by mi- 
croscopical and clinical research. Leyden, indeed, has published in a 
recent issue of the Cent. f. Klin. Med., p. 61, a paper on the micro- 
coccus of cerebro-spinal meningitis, and M. Ernest Gandier 1 states that 
he has discovered in the blood and urine of a patient, examined fresh 
and with "antiseptic precautions," micrococci in great abundance. But 
proof is lacking that these micrococci sustain a causative relation to 
the disease. 

At the debates in the Academy the question was raised whether the 
cause might not reside in the cereals or some other agricultural products. 
This is improbable, for of tAvo adjacent localities, in which the diet of the 
inhabitants is the same, one escapes and the other is visited by the 
epidemic. The disease ceases after a. time, although the food of the 
people remains unchanged. Infants at the breast having only the 

1 Rev. Medicale, June 3, 1882 ; New York Medical Record, September 9, 1882. 



ETIOLOGY 



359 



mother's milk are sometimes affected, and likewise certain animals 
whose food is very different from that of man, and finally the most 
careful examinations have hitherto failed to discover any dietetic cause 
of the malady. That the cause does not emanate from the soil, directly 
at least, is probable from the fact that many epidemics commence in the 
winter when the ground is frozen, and that they occur in localities where 
there is every kind of soil and the most diverse geological formations. 
Probably, therefore, the cause, whatever its origin and nature, resides 
in the atmosphere, and enters the system through those channels which 
receive air. Prof. Wm. H. Welch writes to me on this subject: 
" Worthy of consideration, though unproven, is the view of Medin, that 
the infectious material is absorbed by the lymph-spaces of the nasal 
mucous membrane, which, according to Key and Retzius, communicate 
on the one side with the atmosphere through openings between the epi- 
thelial cells, and on the other side with the subarachnoid spaces at the 
base of the brain." 

Among the conditions which are favorable for the occurrence of cere- 
brospinal fever, and may therefore be regarded as predisposing to it, 

Fig. 25. 




we may mention the winter season. Statistics collected in Europe 
and the United States show that while 166 epidemics occurred in 
the six months commencing with December, only 50 were in the 
remaining six months of the year. According to the statistics of Prof. 
Hirsch, which were collected mainly from Central Europe, 57 epidemics 
were in winter or winter and spring, 11 in spring, 5 between spring and 
autumn, 4 commenced in autumn and extended into winter, or into winter 
and the ensuing spring, and 6 lasted the entire year. I suspect that the 
opinion expressed by Prof. Hirsch is correct, that the excess of epi- 
demics in the winter months is due mainly to the greater crowding and 
less ■ ventilation in the domiciles during the cold than warm months, 
especially among European peasantry. In New York City, where the 
state of the domiciles is about the same the year round, the season 
appears to exert little influence on the prevalence of the disease. 

All observers have remarked the fact that anti-hygienic conditions 
increase the liability to cerebro-spinal fever ; in other words, produce 



3G0 CEREBRO-SPINAL FEVER. 

such a state of system that it more readily yields to the morbific influ- 
ence and contracts the malady. Hence soldiers in barracks and the 
poor in tenement houses suffer most severely when the epidemic is pre- 
vailing. In New York City the fact is often remarked that multiple 
cases occur for the most part where obvious unsanitary conditions exist, 
as in apartments which are unusually crowded and filthy, or in tene- 
ment-houses around which refuse matter has collected, or which have 
defective drainage. The interesting chart prepared under the direction 
of Dr. Moreau Morris for the Health Board, shows that comparatively 
few cases occurred in the epidemic of 1872 in those portions of the city 
where the sanitary conditions were good. Anti-hygienic conditions prob- 
ably predispose to cerebro-spinal fever in the same way that they do to 
other grave epidemic disease, as, for example, to Asiatic cholera, whose 
ravages are chiefly where hygienic requirements are most neglected. 
We will presently relate striking examples which show how foul air 
increases the number and malignancy of cases. 

Is Cerebrospinal Fever Contagious? — It is the almost unanimous 
opinion of those who are most competent to judge from their observa- 
tions, that it is either not contagious or is contagious in only a slight 
degree. It is certain that the vast majority of cases occur without the 
possibility of personal communication. Thus, in the commencement of 
an epidemic, the first patients are affected here and there, at a distance 
from each other, often miles apart, and throughout an epidemic, usually 
only one is seized in a family. Children may be around the bedside of 
the patient, passing in and out of the room without restriction, and yet 
we can confidently predict that none of them will contract the malady, 
if there be proper ventilation and cleanliness, and none of the conditions 
of insalubrity exist within or around the domicile. Moreover, when 
multiple cases occur in a family, the disease begins at such irregular 
intervals in the different patients, that there can be little doubt in most 
instances that it is not communicated from one to the other, but, like 
the fevers from marsh miasm, is produced by exposure to the same 
morbific cause, existing outside the individuals, but within or around 
the premises. Thus in the Brown family treated by the late Dr. John 
G. Sewall, 1 of New York. The first child sickened January 30th, and 
subsequently the remaining five children at intervals respectively of 
five, seven, eleven, twenty-five, and forty-five days. That so many 
were affected in one family was attributed by the doctor to the filthy 
state of the house and the bad plumbing, which allowed the free escape 
of sewer-gas. In my own practice, in the family which suffered the 
most severely of all, four patients were seized in succession, and yet 
I could see no evidence of contagiousness. The family occupied a 
small plot of ground, not more than thirty feet by one hundred, and 
their occupation was to prepare for the meat-market what is known as 
head-cheese. They lived on the second floor of the two-story wooden 
house in which the work was carried on. At the time of the sickness 
the shop contained four hundred heads of animals from which the 
meat for the cheese was obtained, and evidently more or less decaying 
animal matter was present. The occupation and surroundings of this 

1 Medical Record, July, 1872. 



ETIOLOGY. 361 

family afforded sufficient explanation of the fact that so many were 
attacked. Two workmen contracted the disease within about one week 
of each other, and were removed from the house. Four weeks after the 
commencement of the malady in the workman who was first attacked, 
on January 26th, one child sickened with it, and died on February 1st. 
Fifteen days subsequently (February 16th) a second child was attacked 
by it, and after a tedious sickness finally recovered. The long and 
irregular intervals between these cases indicate that the disease was not 
contracted by one from the other. The important factor in causing so 
severe an outbreak of cerebro-spinal fever in this family was probably 
the miasm produced by such an occupation in the house where the 
family resided, with neglect of ventilation and cleanliness. 

But the strongest evidence that cerebro spinal fever is either non- 
contagious, or very feebly contagious, is afforded by the fact that a 
large majority of the cases occur singly in families, although there is 
no isolation of the patients. The following are the statistics relating to 
this point of the cases which I have observed since cerebro-spinal fever 
commenced in New York, in 1871 : Single cases occurred in seventy 
families ; dual cases occurred in nine families ; three cases occurred in 
one family, and four cases in one family. Intercourse with the sick- 
room was unrestricted in all these families, so that children frequently 
went out and in, and sometimes assisted in the nursing. 

The most striking example of apparent contagiousness which has 
come to my knowledge was related by Hirsch, and is quoted by von 
Ziemssen. A young man sickened with cerebro-spinal fever on Feb- 
ruary 8th. The woman who nursed him returned to her home in a 
neighboring village and there died of the same disease on February 26th. 
To her funeral mourners came from a neighboring township, and after 
their return home three of them died with the same disease, one within 
twenty-four hours, another on March 4th, and a third on the 7th. 

In one instance only in my practice did the facts point to contagious- 
ness. A boy of twelve years died of cerebro-spinal fever and was buried 
on Saturday or Sunday. On Monday the mother washed the linen and 
bedclothes of the boy, which had accumulated and were in a very filthy 
state. Two days subsequently she was attacked, and her infant soon 
afterward, both perishing. The state of the bedding and apartments 
in this house, as seen by myself, was such as would be likely to concen- 
trate and intensify the poison, rendering it peculiarly active, for they 
were very dirty, and the mother, exhausted by her long and incessant 
watching and lack of sleep, and depressed by grief, rendered her system 
more liable to the disease by her self-imposed duties on the day after the 
funeral. One in her state of mind and body, standing for a consider- 
able part of a day over the bedclothes and bedding of her child, soiled 
by the excreta, would certainly be in a condition to contract the disease 
if it were in any, even in the lowest degree, contagious. In the present 
state of our knowledge, therefore, upon this important subject, the evi- 
dence leads us to believe that with proper ventilation and cleanliness, 
and the suppression of anti-hygienic conditions in an infected domicile, 
those who are in a good state of body and mind will not contract the 



362 CEREBRO-SPIXAL FEVER. 

disease, but in the opposite conditions it is not improbable that the 
poison may be so intensified, and the system rendered so liable to receive 
the prevailing malady, through impairment of the general health and 
diminished resisting power, that cerebro-spinal fever may, though rarely, 
be communicated either by the breath of the patient, or by exhalations 
from his surface, or from soiled clothing. If so, it of course possesses a 
low decree of contagiousness. 

The occurrence of cerebro-spinal fever in certain of the lower animals 
is a very interesting fact, especially as the question is sometimes asked 
whether it may not be communicated from them to man. In the epi- 
demic of 1811 in Vermont, according to Dr. Gallop, even the foxes 
seemed to be affected, so that they were killed in numbers near the 
dwellings of the inhabitants. Cerebro-spinal fever, previously unknown 
in New York City, began, as stated above, in 1871, among the horses 
in the large stables of the city car and stage lines, disabling many and 
proving very fatal, while among the people the epidemic did not properly 
commence till January, 1872, although a few isolated cases occurred in 
December of 1871. No evidence exists, so far as I am aware, that the 
disease was, in any instance, communicated by these animals to man. 
Those who had charge of the infected horses, as the veterinary surgeons 
and stablemen, did not contract the malady, certainly not more frequently 
than others who were not so exposed. Although we may admit slight 
contagiousness, there has probably been no well-established example of 
the transmission of cerebro-spinal fever from animals to man. If trans- 
mission ever does occur, it is so rare that practically no account need be 
made of it. 

In some instances we are able to discover an exciting cause. An 
individual whose system is affected by the epidemic influence, may 
perhaps escape by a quiet and regular mode of life, but if there be any 
unusual excitement, or the normal functional activity of the system be 
seriously disturbed, an outbreak of the malady may occur. Among the 
exciting causes we may mention over-work and lack of sleep, fatigue, 
mental excitement, depressing emotions, prolonged abstinence from food 
followed by over-eating, and the use of indigestible and improper food. 
Thus in one instance among my cases, a delicate young woman, at the 
head of one of the departments in a well-known .Broadway store, was 
anxious and excited, and her energies overtaxed, at the annual reopen- 
ing. Within a day or two subsequently the disease began. Another 
patient, a boy, was seized after a day of unusual excitement and exposure, 
having in the meantime bathed in the Hudson when the weather was 
quite cool. Those children have seemed to me especially liable to be 
attacked who were subjected to the severe discipline of the public 
schools, returning home fatigued and hungry and eating heartily at a 
late hour. In one instance which I observed, a school-girl, ten years 
of age, returned from school excited and crying because she had failed 
in her examination and had not been promoted. In the evening, after 
she had closely studied her lessons, the fever began with violent headache. 

Dr. Frothingham 1 writes as follows of the brigade in which cerebro- 

1 American Medical Times, April 30, 1864. 



sex. 363 

spinal fever occurred in the Army of the Potomac: ''Under General 
Butterfield. a stern disciplinarian. . . . the men were drilled to 
the full extent of their powers, often to exhaustion. I did not at the 
time recognize this as the cause of the disease in question, but I learnt 
that in the present epidemic in Pennsylvania the attack generally fol- 
lows unusual exertion and exposure to cold." 

Many observers have noticed that bodily fatigue and mental depres- 
sion and excitement are important factors in causing an attack of cerebro- 
spinal fever, when this disease is epidemic. Dr. Gallop, in his history 
of cerebrospinal fever, as it occurred in Vermont in 1811, directs 
attention to the severity of the cases among the troops under General 
Dearborn, who were fatigued by marches and greatly dispirited on 
account of a repulse which they had just sustained from the British. In 
one case, which occurred in my practice, a boy. six years and eleven 
months of age. was punished at school and came home with cheeks 
flushed from excitement, the excitement continuing during; the ensuing 
night. On the following day cerebrospinal fever began with vomiting 
and chilliness, the attack ending fatally on the seventeenth day. In an- 
other case, which was related to me by the mother and the physician, the 
patient, a bright girl, twelve years of age. of nervous temperament, and 
forward in her studies, had been much excited in competing for a prize 
in athletic exercises. In the evening of the same day a violent thunder- 
storm occurred, and after a severe clap she started from bed. pallid and 
excited, and expressed the belief that she had been struck by lightning. 
The disease began immediatelv after this, and terminated fatallv on the 
fifth day. 

Sex, — It is stated by certain writers that more males are affected 
than females. The statistics of hospitals and camps show this ; for men 
subject to lives of hardship are especially liable to be attacked, but in- 
family practice, in which a large proportion of the patients are children, 
the number of males and females is about equal. Thus in 105 cases. 
occurring chiefly in my practice, but a few of them in the practice of two 
other physicians of this city. I find that 59 were males and 46 females. 
Ninety-one of these were children. In Xew York City, during the 
epidemic of 1872, 905 cases of cerebro-spinal fever were reported to 
the Health Board between January 1st and November 1st. and of these 
4 V 4 were males and 421 females. Dr. Sanderson's statistics of the 
epidemic in the provinces around the Vistula, the cases being chiefly 
children, give also but a slight excess of males. Probably, therefore, in 
the same conditions and occupations of life the sexes are equally liable 
to contract this malady, and the excess of males is due to the fact that 
they lead a more irregular life, and are more subject to privations and 
exposures. That soldiers on duty or in barracks have been attacked 
while families in the vicinity escape, thus increasing the proportion of 
male cases, must be due to irregularities, hardships, and perhaps the 
lack of sanitary regulations in the mode of their life. 

Age. — Children, as already stated, are much more apt to contract 
cerebro-spinal fever than adults. The following are the statistics of the 
X. Y. Health Board relating to the age of the cases during the epidemic 



36-i CEREBRO-SPINAL FEVER. 

Under 1 year 125 

From 1 to 5 years 336 

From 5 to 10 " 204 

From 10 to 15 " 106 

From 15 to 20 " 54 

From 20 to 30 " 79 

Over 30 years 71 

Total 975 

In the cases which occurred in my own practice, and in a few cases 
in the practice of other physicians added to mine, I find that the ages 
were as follows: 

Under 1 year 16 

From 1 to 3 years 27 

From 3 to 5 " 25 

From 5 to 10 " 20 

From 10 to 15 " . . .10 

Over 15 years 15 

Total 113 

In my practice, therefore, three-fourths of the cases have been under 
the age of ten years, and the statistics of epidemics in other localities 
correspond with mine in giving a large excess of cases in childhood. 
Thus Dr. Sanderson, in examining the records of deaths in one epi- 
demic ascertained that two hundred and eighteen had perished under 
the age of fourteen years, and only seventeen above that age ; and 
although this does not show the exact ratio of children to adults in the 
entire number of cases, it is evident that the children were greatly in 
excess. 

The more advanced the age after the tenth year, the less the liability 
to this malady, so that very few who have passed the thirty-fifth year 
are attacked, and old age possesses nearly an immunity. In New York 
City, in which, as we have seen, cerebro-spinal fever has been occurring 
since 1871, only two cases have come to my knowledge which had 
passed the fortieth year. The age of one was forty-seven, and the other 
sixty-three years. 

Symptoms. — During the prevalence of cerebro-spinal fever cases now 
and then occur in which the symptoms are mild and transient, and the 
health is soon fully restored. It seems proper to regard some, at least, 
of these as genuine but aborted forms of the disease. The following 
cases which occurred in my practice may be cited as examples : 

A boy, eight years of age, previously well, was taken with headache, 
vomiting, and moderate febrile movement, on April 2, 1872. The evacua- 
tions were regular and no local cause of the attack could be discovered. 
On the following day the symptoms continued, except the vomiting, but 
he seemed somewhat better. On April 4th the febrile movement was 
more pronounced, and in the afternoon he was drowsy and had a slight 
convulsion. The forward movement of the head w T as apparently some- 
what restrained. On the 6th the symptoms had begun to abate, and in 
about one week from the commencement of the attack his health was fully 
restored. 

A boy, aged six, was well till the second week in May, 1872, when he 



MODE OF COMMENCEMENT. 365 

became feverish and complained of headache. At my first visit, on May 
14th, he still had headache, with a pulse of 112. The pupils were sen- 
sitive to light, but the right pupil was larger than the left. The bromide 
and iodide of potassium were prescribed, with moderate counter-irritation 
behind the ears. The headache and febrile movement in a few days 
abated, the equality of the pupils was restored, and within a little more 
than one week from the commencement of the disease he fully recovered. 

These cases occurred when the epidemic of 1872 was at its height; 
but if the symptoms are so mild, and the duration of the disease short, 
as in these two cases, the diagnosis must sometimes be doubtful. Ob- 
servers in different epidemics report similar cases, and as the symptoms, 
so far as they appeared in my patients, seemed characteristic, I have 
not hesitated to regard them as genuine but aborted cases. On such 
patients the epidemic influence acts so feebly, or their ability to resist it 
is so great, that they escape with a short and trivial ailment. 

Occasionally, also, during the progress of an epidemic, we meet 
patients who present more or few T er of the characteristic symptoms, but 
in so mild a form that they are never seriously sick, and never entirely 
lose their appetite, but the disease, instead of aborting, continues about 
the usual time. 

Thus, on January 4, 18T3, I was called to a girl aged thirteen, who 
had been seized with headache followed by vomiting in the last week in 
December. During a period of six to eight weeks, or till nearly March 
1st, she had the following symptoms : Daily paroxysmal headache, often 
most severe in the forenoon ; neuralgic pain in the left hypochondrium, 
and sometimes in the epigastric region ; pulse and temperature some- 
times nearly normal, and at other times accelerated and elevated, both 
with daily variations ; inequality of the pupils, the right being larger 
than the left during a portion of the sickness. The patient was never 
so ill as to keep the bed, usually sitting quietly during the day in a 
chair or reclining on a lounge, and she never fully lost her appetite. 
Quinine had no appreciable effect on the fever or paroxysms of pain. 
There can, in my opinion, be little doubt that this girl was affected by 
the epidemic, but so mildly that there was, for a considerable time, 
much uncertainty in the diagnosis. 

Cases like these, in which the disease is so feebly developed that the 
patient is never seriously sick, though unimportant pathologically, must 
be recognized in a treatise on cerebro-spinal fever. 

Mode of Commencement. — Cerebro-spinal fever rarely begins in the 
forenoon after a night of quiet and sound sleep. In the cases which I 
observed in the severe and fatal epidemic of 1872, and in the thirty-six 
cases of which I have records observed since 1872, the commencement 
was almost without exception between mid-day and midnight. The 
fact that this disease does not commence after the repose of night, till 
several hours of the day have passed, shows the propriety and need of 
enjoining a quiet and regular mode of life, free from excitement, and 
with sufficient hours of sleep, during the time in which the epidemic is 
prevailing. 

The commencement is usually without premonitory stage, and sudden ; 
unlike, therefore, the beginning of other forms of meningitis, which come 



366 CEREBRO-SPIXAL FEVER. 

on gradually and are preceded by symptoms which, if rightly interpreted, 
direct attention to the cerebro-spinal system. Exceptionally certain 
premonitions occur for a few hours or days before the advent of the 
disease, such as languor, chilliness, etc. Mild cases more frequently 
begin gradually, and with certain premonitions, than severe cases. The 
ordinary mode of commencement is as follows : The patient is seized 
with vomiting, headache, and perhaps a chill or chilliness, so that there is 
a sudden change from perfect health to a state of serious sickness. Rigor 
or chilliness is a common initial symptom, especially in adult patients. 
One patient, an adult female, had three or four chills of considerable 
severity in the commencement of the attack. Children often have 
clonic convulsions in place of the chill, or immediately after it, partial 
or general, slight or severe. Stupor more or less profound, or less fre- 
quently delirium succeeds. In the gravest cases semi-coma occurs 
within the first few hours, in which patients are with difficulty aroused, 
or profound coma, which, in spite of prompt and appropriate treatment, 
is speedily fatal. Those thus stricken down by the violent onset of the 
disease, if aroused to consciousness, complain of severe headache, with 
or without, or alternating with equally severe neuralgic pains in some 
part of the trunk, or in one of the extremities. The pain frequently 
shifts from one part to another. Among the early symptoms of cerebro- 
spinal fever are those which pertain to the eye. The pupils are dilated, 
or less frequently contracted, and they respond feebly, or not at all, 
to light if the attack be severe and dangerous ; often they oscillate, and 
occasionally one is larger than the other. Vomiting with little apparent 
nausea, and often projectile, is common in the commencement of cerebro- 
spinal fever. It occurred as an early symptom in fifty-one of fifty-six 
cases observed by Dr. Sanderson. In ninty-seven cases occurring in 
New York, most of them observed by myself, but a few of them related 
to me by the late Dr. John G. Sewall, vomiting occurred as an early 
symptom in sixty-eight cases. Its absence on the first day was recorded 
in only three cases, while in the remaining twenty-seven patients the 
records of the first day make no mention of its presence or absence. 
It was probably present in most of these twenty-seven cases as one of 
the first symptoms. 

Since the epidemic of 1872, in examining patients now numbering 
thirty-six, as has been already stated, I have made careful inquiry in 
regard to the mode of commencement, and with only two or three excep- 
tions the previous health had either been good, or if symptoms of ill- 
health antedated the cerebro-spinal fever, they were due to some ailment 
entirely distinct from this disease. In a boy four and a half years of 
age, living in Broadway, it was stated to me that the cerebro-spinal fever 
came on gradually,, with pains in the head and elsewhere ; this case was 
mild throughout, and the patient was never in imminent danger. In 
nearly all the cases, if the patients were at home and under observation, 
the exact moment of the beginning of the disease could be stated. Thus 
a man aged twenty-eight returned from his work at midday, April 23, 
1883, in good health and cheerful, ate a hearty meal at 12 M. and at 1 
P. M. had a chill, with intense headache and severe vomiting. Minute red 
points appeared on his face after the vomiting from capillary extravasa- 



SYMPTOMS. 367 

tions. In this case the interesting fact was observed of a cessation of the 
symptoms, so that on the 24th and 25th, being free from pain, he went 
to Brooklyn. On the 26th, however, the symptoms returned. He had 
pains in the head, back, and extremities, and was seriously sick. Occa- 
sional remissions, so that very grave symptoms become mild for a time, 
and then return in full severity, as well as distinct intermissions as in 
this case, have been frequently noticed by observers in different epi- 
demics. A little girl, previously entirely well, was slightly punished 
on June 11, 1882 ; immediately she vomited, and seemed quite sick ; 
by kind nursing on the part of the mother she became better, so that on 
the 12th she had some appetite and went out. On the 13th, cerebro- 
spinal fever began, with a temperature of 103°, and its course was tedious. 
A robust girl, aged thirteen, vivacious and cheerful, went as usual in the 
morning to one of the public schools, entirely well. Before the school 
was dismissed she returned home crying, on account of dizziness and 
violent pain on the top of her head, in her knees, and calves of the legs. 
The case was attended by Professors Alonzo Clark, Knapp, and myself, 
and was fatal after four and a half weeks. A boy, aged ten, returned 
from another public school in a similar manner, having gone to it in the 
morning in apparent perfect health. 

We may, therefore, summarize as follows the symptoms which com- 
monly attend the commencement of cerebro-spinal fever : violent pain 
in some part of the head, and sometimes also in the trunk or limbs, 
vomiting, a chill or chilliness, clonic convulsions, dizziness, dilated, slug- 
gish, or altered pupils, fever of greater or less intensity according to the 
Severity of the attack, heat of head, and in most patients of the surf ice 
generally. If the disease be of a severe and dangerous type these symp- 
toms are frequently followed within a few hours by delirium, semi-coma, 
or coma. 

Symptoms. Nervous System. — Since in cerebro-spinal fever ex- 
tensive and intense inflammation occurs of the cerebral and spinal men- 
inges, with more or less congestion of the brain and spinal cord, lesions 
which we will consider hereafter, we would expect that this disease would 
be attended by severe and dangerous symptoms, inasmuch as the cerebro- 
spinal axis exerts such a controlling influence upon the functions of the 
body. Also we would expect that the symptoms would vary according 
to the portion of the meninges which happens to be most severely in- 
flamed. There is, indeed, variation in symptoms according to the extent 
and intensity of the meningitis, and the degree in which the cerebro- 
spinal axis is congested or implicated, but certain symptoms occur in all 
or nearly all cases, and as they are characteristic they render diagnosis 
easy. 

Pain, already described as an initial symptom, continues during the 
acute period of the malady. It is ordinarily severe, eliciting moans 
from the sufferer, but its intensity varies in different patients. Its most 
frequent seat is the head, and the location of the cephalalgia varies in 
different patients and in the same patient at different times. One refers 
it to the top of the head, another to the occiput, and another to the 
frontal region, and the same patient at different times may complain of 
all these parts. The pain is described as sharp, lancinating, or boring. 



368 CEREBRO-SPINAL FEVER. 

It is also common in the neck, especially in the nucha, the epigastrium, 
umbilical, and lumbar regions, along the spine (rachialgia), and in the 
extremities, where it shifts from one part to another. It is more common 
and persistent in the head and along the spine than elsewhere. The 
patient, if old enough to speak, and not delirious or too stupid, often 
exclaims, "Oh ! my head," from the intensity of his suffering, but after 
some moments complains equally of pain in some other part, while 
perhaps the headache has ceased or is milder. In a few instances the 
headache is absent, or is slight and transient, while the pain is severe 
elsewhere. After some days the pain begins to abate, and by the close 
of the second week is much less pronounced than previously. Vertigo 
occurs with the headache, so that the patient reels in attempting to 
stand or walk. I have stated above that vertigo may be a prominent 
initial symptom, as in the girl of thirteen years, who suddenly became 
sick in the public school where she was attending, and reached her 
home with difficulty -on account of the headache and dizziness. Con- 
tributing to the unsteadiness of the muscular movements is a notable 
loss of flesh and strength, which occurs early and increases. 

The state of the patient's mind is interesting. It is well expressed 
in ordinary cases by the term apathy or indifference, and between this 
mental state and coma on the one hand, and acute delirium on the other, 
there is every grade of mental disturbance. Some patients seem totally 
unconscious of the words or presence of those around them, when it 
subsequently appears that they understood what was said or done. 
Delirium is not infrequent, especially in the older children and adults. 
Its form is various, most frequently quiet or passive, but occasionally 
maniacal, so that forcible restraint is required. It sometimes resembles 
intoxication or hysteria, or it may appear as a simple delusion in regard 
to certain subjects. Thus one of my patients, a boy of five years, ap- 
peared for the most part rational, protruding his tongue when requested, 
and ordinarily answering questions correctly, but he constantly mistook 
his mother — who was always at his bedside — for another person. Severe 
active delirium is commonly preceded by intense headache. In favora- 
ble cases the delirium is usually short, but in the unfavorable it is apt 
to continue with little abatement till coma supervenes. 

On account of the pain and the disordered state of the mind, patients 
seldom remain quiet in bed unless they are comatose, or the disease be 
mild or so far advanced that muscular movements are difficult from weak- 
ness. In severe cases they are ordinarily quiet for a few moments, as 
if slumbering, and then, aroused by the pain, they roll or toss from one 
part of the bed to another. One of my patients, a boy of five years, 
repeatedly made the entire circuit of the bed during the spells of rest- 
lessness. In mild cases, or cases attended by less headache or mental 
disturbance, patients are quiet, usually with their eyes closed, unless 
when disturbed. 

Hypersesthesia of the surface is another common symptom. Few 
patients, not comatose, are free from it during the first weeks, and it 
materially increases the suffering. Friction upon the surface, and even 
slight pressure with the fingers upon certain parts extort cries. Gently 
separating the eyelids for the purpose of inspecting the eyes, and moving 



SYMPTOMS. 369 

the limbs, or changing the position of the head, evidently increase the 
suffering, and are resisted. I have sometimes heard such expressions 
of suffering from slowly introducing the thermometer into the rectum 
that I was led to believe that the anal and perhaps rectal surfaces were 
hypersensitive. The hyperesthesia has diagnostic value, for there is 
no disease with which cerebro-spinal fever is likely to be confounded in 
which it is so great. It is due to the spinal meningitis, and is appre- 
ciable even in a state of semi-coma. The headache and hyperesthesia 
fluctuate greatly in the course of the disease, and the former sometimes 
recurs at times, especially from mental excitement, or from an afflux of 
blood to the brain from physical exertion, for months after the health 
is otherwise fully restored. 

Some contraction of certain muscles or groups of muscles is present 
in all typical cases. In a small proportion of patients it is absent or is 
not a prominent symptom, namely, in those in whom the encephalon is 
mainly involved, the spinal cord and meninges being but slightly affected 
or not all. This contraction is most marked in the muscles of the nucha, 
causing retraction of the head, but it is also common in the posterior 
muscles of the trunk, causing opisthotonos, and in less degree in those 
of the abdomen and lower extremities, and hence the flexed position of 
the thighs and legs, in which patients obtain most relief. The muscular 
contraction is not an initial symptom. I have ordinarily first observed 
it about the close of the second day, but sometimes as early as the close 
of the first day, and in other instances not till the close of the third day. 
Attempts to overcome the rigidity, as by bringing forward the head, are 
very painful, and cause the patient to resist. In young children having 
a mild form of the fever, with little retraction of the head, the rigidity 
is sometimes not easily detected. I have been able in such cases to 
satisfy myself and the friends of its presence, by placing the child in an 
upright position, as on the lap of the mother, and observing the difficulty 
with which the head is brought forward on presenting to the patient a 
tumblerful of cold water, which is craved on account of the thirst. The 
usual position of the patient in bed, in a typical or marked case, is with 
the head thrown back, the thighs and legs flexed, with or without 
forward arching of the spine. The muscular contraction and rigidity 
continue from three to five weeks, more or less, and abate gradually ; 
occasionally they continue much longer. Through the kindness of Dr. 
Henry Griswold I was allowed to see an infant of seven months in the 
tenth week of the disease. It was still very fretful, and exhibited decided 
prominence of the anterior fontanelle, probably from intracranial serous 
effusion and marked rigidity of the muscles of the nucha, with retrac- 
tion of the head. 

Paralysis is another occasional symptom, but complete paralvsis of 
any muscle or group of muscles is less frequent than one would suppose 
from the nature of the malady. It may occur early, but is sometimes 
a late symptom. It may be limited to one or two of the limbs, as the 
legs, or an arm and a leg, or it may be more general. In a case occur- 
ring in Roosevelt Hospital, and published in the New York Medical 
Record for October 10, 1878, the patient, a boy of ten years, was 
unable to move his legs one hour after the commencement of the disease. 

24 



370 CEREBROSPINAL FEVER. 

This sudden development of paraplegia in the commencement of cerebro- 
spinal fever resembled that of infantile paralysis, and was probably due 
to the same cause, to wit, active inflammatory congestion of the an- 
terior cornua of the spinal column. The sudden and complete loss 
of speech which occurs in certain cases, when consciousness is retained 
and the vocal organs are in their normal state, seems to be due to the 
fact that the portion of the brain which controls the function of speech 
is acutely congested, or is the seat of effusion. Thus in June, 1882, a 
girl of three years, whom I attended, lost her speech on the second day 
of cerebro-spinal fever, and she was unable to articulate even the sim- 
plest word for two and a half months. Finally she began to utter slowly 
and with difficulty the easiest monosyllables, and now, after a lapse of 
more than a year, her speech is slow and lisping, while her hands are 
tremulous and unsteady. She is easily fatigued and cries often from 
over-sensitiveness. During the long period of speechlessness she daily 
made efforts to talk, but without uttering a sound. Strabismus, to 
which we will allude hereafter in treating of the eye, is a common symp- 
tom, either transient or protracted, due to paralysis of certain of the 
motor muscles of the eye. 

Paralysis of more or fewer muscles has been noticed and recorded by 
many observers in this country and in Europe. Dr. Law observed a 
patient in the epidemic of 1865, in Dublin, who could move neither 
arms nor legs, and Wunderlich saw one who had paralysis of both lower 
extremities and a considerable part of the trunk. As this symptom is 
due to the inflammatory process in the cerebro-spinal axis, it usually 
disappears in a few weeks as the inflammation abates and absorption of 
the inflammatory products occurs, but it may be more protracted. In 
Wunderlich 's case there was only partial recovery from the paralysis 
after the lapse of five months. 

Clonic convulsions have already been alluded to among the early 
symptoms of the attack. They indicate a grave form of the disease, 
and are not infrequent in young children, in whom they appear to occur 
in place of the chill which is common in those of a more advanced age. 
The eclamptic attack may be short and not repeated, or it may be pro- 
tracted, or return again and again when the medicines which control it 
are suspended. Under such circumstances it is apt to end in profound 
coma, and is, of course, a symptom of great gravity. Thus an infant 
of seven months had unilateral eclamptic attacks daily during the first 
week of the attack. The mother informed me that the convulsions 
seldom lasted longer than three minutes, and that the intervals between 
them were short. The child recovered with loss of sight from the 
cerebro-spinal fever, but still after the lapse of a year, when I exam- 
ined him, had symptoms which were apparently due to hydrocephalus. 
Another infant of eleven months had clonic convulsions nearly con- 
stantly during the first twenty-four hours, but with occasional brief 
intermissions. On the following day he was in profound coma, and 
apparently dying, with a temperature of 105°. To my astonishment 
he gradually emerged from the state of unconsciousness, and after a 
week was able to sit in his cradle long enough to take drinks. 

Occasionally eclampsia does not occur in the first days, but in the 



DIGESTIVE SYSTEM. 371 

second or third week, when it is usually accompanied by an increase of 
other symptoms, due to a recrudescence of the disease. A female 
infant, aged eleven months, treated by me in 1882, had been sick one 
week, when, during an increase in the febrile movement, she had one 
eclamptic seizure. Her recovery though slow was complete. A boy, 
aged eleven and one-half years, whose attack began with a chill, violent 
headache, and a febrile movement, and whom I visited frequently, died 
on the fourth day. Clonic convulsions did not occur in his case until 
within twenty-four hours of his death, when he had six seizures, which 
ended in coma. 

Though adult patients are much less liable to eclampsia than children, 
they are not entirely exempt. A male patient, aged twenty-eight years, 
whom I saw in consultation, had a single clonic convulsion lasting ten 
to fifteen minutes on the third day of his illness. In five weeks he had 
fully recovered, except that his headache returned upon any excitement. 
Even drinking a cup of beer caused it. Clonic convulsions are, how- 
ever, much less common than tonic muscular contraction and rigidity 
already alluded to. This occurs to a greater or less extent in nearly 
all cases, and is a symptom of diagnostic value, the rigidity often ex- 
tending to the muscles of the extremities. Thus in a child, aged three 
years, who had no eclampsia, the tonic contraction of the muscles of the 
extremities did not relax till after the twelfth day. 

Choreic or choreiform movements are occasionally observed. I do 
not allude to the tremulousness which sometimes occurs from weakness, 
or as a premonition of eclampsia, but a movement which has the char- 
acter of true chorea. An infant, aged ten months, began to have choreic 
movements during the acute stage of the disease, most marked in the 
upper extremities, and ceasing in sleep. They continued during the 
remainder of the life of the child, death occurring ten months subse- 
quently from diphtheria. Rarely a choreiform movement of the eyes is 
also observed, a lateral movement from right to left, and left to right. 
I have seen from recollection two such cases. 

Drowsiness, already alluded to, is a common symptom, and it exists 
in all grades, from slight stupor to profound coma. In some patients 
it is present from the first hour, while in others it occurs after a period 
of restlessness or delirium, or it alternates with it. Stupor more or less 
profound is common after the attack of eclampsia or the chill. That it 
is a frequent symptom in severe cases receives ready explanation from 
the state of the brain and its meninges, for the exudation which occurs 
upon the surface of the brain and the serous effusion within the ven- 
tricles are sufficient to cause it, by compressing the cerebral substance. 
It is surprising in some cases how profound the stupor may be, a state 
indeed of coma, and yet the patient gradually emerges from it and 
recovers. In the epidemic of 1872, in New York City, when the 
malady was new with us, many physicians predicted certain death, and 
employed remedies without expectation of any benefit, on account of the 
apparently hopeless state of patients, who seemed to be in profound 
coma, and yet not a few of them gradually and fully recovered . 

Digestive System. — Vomiting, which is the most prominent symp- 
tom referable to the digestive system, has already been alluded to. 



372 CEREBRO-SPINAL FEVER. 

Occurring early in the disease, it may cease in a few hours, or not till 
after several days, and often it returns during the periods of recrudes- 
cence which are common in the progress of the fever. It occurs with 
little effort, and without previous nausea, or with little nausea, as is 
usual when it has a cerebral origin. It does not differ as a symptom 
from the vomiting which is so common in other forms of meningitis. 
The substance vomited consists of the ingesta and the secretions, as 
mucus and bile. Having a similar origin is a sensation of faintness or 
depression referred to the epigastrium. 

The appetite is usually impaired or lost during the active period of 
the attack, and it is not fully restored till convalescence is well advanced. 
Occasionally considerable nutriment is taken, and with apparent relish, 
as by one of my patients, twenty-eight years of age, who always had 
some appetite. Ordinarily, on account of repeated vomitings, constant 
febrile movement, impaired appetite and digestion, patients progressively 
lose flesh and strength, so that in protracted cases emaciation is always 
a prominent symptom, and is often extreme. Great emaciation and loss 
of strength, which attend many cases after the lapse of several weeks, 
greatly diminish the chances of a favorable termination. Thirst, already 
alluded to, and constipation are common in this as in other forms of 
meningitis, but retraction of the abdomen is not a notable symptom, 
except in protracted and greatly wasted cases. The diarrhoea which is 
occasionally present in cerebro-spinal fever in the summer months must 
be regarded as a distinct disease and a complication. The tongue, buccal 
and faucial surfaces present nothing unusual in their appearance. It is 
seldom that the sordes and dry and brownish fur occur, which are so 
common in typhus and typhoid fevers, even in the most protracted and 
emaciated cases. The tongue is usually moist and but slightly furred. 

I have seen in consultation two patients that perished early with in- 
ability to swallow as the prominent symptom, attended in both, by an 
abundant secretion upon the faucial surface, without any redness, swell- 
ing, or other evidence of inflammation. The early death of these young 
children, whose ages were ten months and two years, rendered the diag- 
nosis less certain than in most other patients, but the attending physi- 
cians as well as myself diagnosticated cerebro-spinal fever with suddenly 
developed paralysis of the muscles of deglutition, so that no nutriment 
could be taken. If our understanding of these interesting cases is cor- 
rect, the paralysis was caused by lesion of that portion of the medulla 
oblongata which controls the function of deglutition, or else from injury 
of the intracranial portions of the nerves which supply the muscles con- 
cerned in this act. The following were the cases alluded to : 

O ■, male, two years of age, became feverish and dull, but without 

vomiting, on October 22, 1882 ; axillary temperature, 102°. On the fol- 
lowing day inability to swallow occurred, and the muscles of degluti- 
tion appeared totally inactive. Death occurred on the third day, suddenly, 
and apparently easily, as if from arrested function of important nerves, 
especially the pneumogastric. The abundant secretion of thin mucus or 
transudation of serum covering the faucial surface, and reaccumulating as 
soon as removed, without any notable change in the appearance of the 
fauces, was remarkable. The physician in attendance, who for more than 



TEMPERATURE. 373 

thirty years had had a large city practice, had seen no similar case, nor 
had I at the time. 

Soon afterward the second case occurred. An infant of ten months, 
without cough or embarrassment of respiration, or faucial redness or 
swelling, lost the power of deglutition soon after the commencement of the 
supposed cerebro-spinal fever, so that in the attempts to swallow the drinks 
entered the larynx, and the secretion or exudation was abundant as in the 
other case. Death occurred in forty-eight hours. The rectal tempera- 
ture was only 101°. 

In another case, ultimately fatal, and in which the diagnosis of 
cerebro-spinal fever was certain, a robust girl, aged twelve, suddenly 
lost the power of deglutition at one time during her sickness, although 
she was entirely conscious and repeatedly endeavored to swallow. The 
ability to swallow returned in a few days. 

Pulse. — This is usually accelerated, and the more severe and dan- 
gerous the attack, the more rapid the heart's action, except occasionally 
in the comatose state, when probably, in consequence of compression of 
the brain from an abundant exudation, the pulse may be subnormal. 
Thus, in one of my patients, an adult, the pulse fell to 40 per minute, 
and in two others between 60 and 70 per minute. With the exception 
of these three patients, the pulse in all cases which I have observed, so 
far as I recollect, has varied from the normal number of beats per 
minute to such frequency that it was difficult to count it. As death 
draws near the pulse ordinarily becomes more frequent and feeble. 
Intermissions in the pulse do not seem to be as common as in other 
forms of meningitis, but marked variations in its frequency during dif- 
ferent hours of the day, and on consecutive days, is a conspicuous 
symptom. Thus, in a case w T hich was fatal in the fifth week, consecu- 
tive enumerations of the pulse, in the acute stage, w^ere as follows, 128, 
120, 88, 130, 84, 112. 

Temperature. — Some of the older writers, before the days of clin- 
ical thermometry, stated that the temperature is not increased. North 
remarked as follows : " Cases occur, it is true, in which the temperature 
is increased above the natural standard, but these are rare," and Foot 
and Gallop make similar statements. Some recent writers have held 
the same opinion. Thus Lidell wrote as follows in a treatise bearing 
the date of 1873: ". . . . Febrile symptoms do not necessarily 
belong to epidemic cerebro-spinal meningitis, as a substantive disease, 
for it may, and not unfrequently does occur, without exhibiting any 
such symptoms." We would naturally expect that meningitis, accom- 
panied as it is by active congestion of the brain and spinal cord, would 
produce more or less fever, and in eighty-six cases which I have exam- 
ined by the thermometer, I have found elevation of temperature in 
every case during the acute stage, except in the beginning of the attack 
in two instances. In a young man, aged twenty-eight years, who had 
severe headache and seemed seriously sick, the thermometer under the 
tongue showed no rise of temperature on the first and second days, but 
on the third day it was at 100°, and it remained elevated till his death, 
on the thirteenth day. The second case was that of a young woman 
whom I saw in consultation, and who at the time of my visit had 



374 CEREBRO-SPINAL FEVER. 

decided febrile movement, but who, like the young man, had no rise of 
temperature on the first and second days, according to the careful obser- 
vations of the attending physician. In the eighty-six cases which I have 
examined, the heat of the surface occasionally did not seem above normal 
to the touch, and now and then the thermometer, applied in the axilla 
or groin, did not indicate fever, but the rectal temperature was always 
elevated above that of health after the disease was fully established. 
The temperature fluctuated from day to day, and in different hours of 
the same day, but there was no exception after the second day to the 
rule, that it is supra-normal during the active stage of the malady. 
Sometimes the elevation of temperature was slight, as in a female 
patient, forty-seven years of age, whom I was allowed to examine with 
the family physician. The thermometer showed no elevation of tem- 
perature when it was placed in the mouth and axilla, but on introducing 
it into the rectum it rose to 99J°. 

The highest temperature which I have thus far observed, was 107f-°, 
in a child aged two years. This was in the commencement of the attack. 
Subsequently it fell a little, but rose again on the third day to 107°, 
when she died. In two other cases the temperature was 106° on the 
first day, and it did not afterward reach so high an elevation. One of 
these died on the ninth day, and the other in the ninth week. The 
next highest temperature was 105-4-° , also on the first day, in an infant 
aged eight months, who died on the ninth day. The first and last of 
these cases occurred in an old wooden tenement-house in the suburbs 
of the city, and upon an elevated outcropping of rock. The highest 
temperature in any case in New York City which has come to my 
notice, was observed in a male patient aged twenty-eight years, who 
had active delirium and died on the fifth day in Roosevelt Hospital. 
The temperature on the last day, taken four times, was as follows: 
102J°, 106J °, and when the pulse had become imperceptible, 109° and 
107J ° Wunderlich has recorded a temperature of 110° in one or two 
cases, but so great an elevation must be very rare, and is, of course, 
prognostic of an unfavorable ending. 

The external temperature undergoes still greater fluctuations than 
the internal, rising; above and falling; below the normal standard several 
times in the course of the same day. Similar fluctuations occur in other 
forms of meningitis, but they are, according to my experience, less pro- 
nounced than in cerebro-spinal fever, especially as I observed them in the 
epidemic of 1872. Perhaps since that epidemic they have been less 
marked in the cases occurring in this city. The more grave the attack 
in those not comatose, the greater these variations. The following is a 
common example, in a patient aged two years. Without any notable 
change in other symptoms, the internal temperature varied from 101° 
to 1044° as the extremes, while that of the finders and hands at the 
first examination was 90J°, at the second 90°, at the third 103°, and 
at the fourth 83°. Hence at the third examination the temperature of 
the extremities had risen 13°, so as nearly to equal that of the blood, and 
at the fourth examination it had fallen 20°. The patient recovered. 
These great and sudden variations in the pulse, and the internal and 



RESPIRATORY SYSTEM. 375 

external temperature, have considerable diagnostic value in obscure and 
doubtful cases. 

Respiratory System. — This system is not notably involved in ordi- 
nary cases. Intermittent, sighing, or irregular respiration appears to 
be less frequent than in ordinary meningitis, but it does occur. In 
most patients the respiration is quiet, but somewhat accelerated, and 
without any marked disturbance in its rhythm. In thirty-one observa- 
tions in children who had no complication, I found the average respira- 
tions 42 per minute, while the average pulse was 137. Therefore the 
respiration, as compared with the pulse, was proportionately more fre- 
quent than in health, due perhaps to the fact that certain muscles con- 
cerned in respiration, as the abdominal, are embarrassed in their 
movements by tonic contraction. 

Various observers, in different epidemics, have recorded an unusual 
prevalence of croupous pneumonia occurring simultaneously with the 
cerebro-spinal fever. Bascome, in his history of epidemics, stated that 
" epidemic encephalitis and malignant pneumonias prevailed in Ger- 
many in the sixteenth century" (Webber). Webber, in his prize essay, 
describes a variety of cerebro-spinal fever, which he designates pneu- 
monic, in which the cerebro-spinal axis is involved but slightly or not 
at all, and the brunt of the disease falls upon the respiratory organs. 
According to him, in certain epidemics the pneumonic form has been 
common and in others infrequent. 

In New York City, during the epidemic of cerebro-spinal fever in 
1872, pneumonia was also unusually prevalent, affecting many old as 
well as young people. According to the statistics of the New York 
Board of Health, seventeen hundred and seven deaths from diseases of 
the respiratory organs, exclusive of phthisis, occurred during the four 
months from February 1 to June 1, 1872, when the epidemic of cere- 
bro-spinal fever was at its height, and only thirteen hundred and forty- 
six deaths occurred from the same diseases during the remaining eight 
months of the year ; and as phthisis is excluded, the only other disease 
of the respiratory system besides pneumonia which causes a large mor- 
tality is membranous croup, which did not seem to be unusually preva- 
lent during these four months. It is therefore probable, though not 
distinctly stated in the annual report of the Health Board for that year, 
that the great mortality from diseases of the respiratory organs, during 
that part of 1872 when cerebro-spinal fever was epidemic, was chiefly 
from pneumonia, and, according to my observations, many cases of 
pneumonia during that period presented symptoms of greater gravity 
than usually accompany this form of inflammation. The patients were 
greatly prostrated from the first, and in some of them febrile movement, 
muscular pains, restlessness, or delirium preceded for hours or even days 
the pneumonic symptoms, affording evidence that the lung disease 
occurred under certain unusual circumstances or conditions which modi- 
fied its character. It is not improbable therefore that Webber's view 
is correct, that there are occasional cases of cerebro-spinal meningitis 
with pneumonia as one of its local manifestations. In the New York 
epidemic of 1872 a prominent citizen had a severe attack of what was 
supposed to be cerebro-spinal fever, one of his medical advisers being 



376 CEREBRO-SPIXAL FEVER. 

known throughout the country for his ability in diagnosis. On the 
sixth day the cerebro-spinal symptoms considerably abated, pneumonia 
appeared, and subsequently the prominent symptoms were referable to 
the lungs. He slowly recovered. 

Cutaneous Surface. — The features may be pallid, of normal ap- 
pearance or flushed in the first days of the disease, but in advanced 
cases they are pallid, as is the skin generally. A circumscribed patch 
of deep congestion often appears, as in sporadic meningitis, upon some 
part of them, as the forehead, cheek, or an ear, and after a short time 
disappears. The hyperoemic streak, the tache cerebrale of Trousseau, 
produced by drawing the finger firmly across the surface, also appears 
as in other forms of meningitis, if the temperature of the surface be not 
too much reduced. 

The following are the abnormal appearances of the skin most fre- 
quently observed : 1. Papilliform elevations, the so-called goose-skin, 
due to contractions of the muscular fibres of the corium. This is not 
uncommon in the first weeks. 2. A dusky mottling, also common in 
the first and second weeks in grave cases, and most marked when the 
temperature is reduced. 3. Numerous minute red points over a large 
part of the surface, bluish spots a few lines in diameter, due to extrava- 
sation of blood under the cuticle, resembling bruises in appearance, and 
large patches of the same color, an inch or more in diameter, less com- 
mon than the others, of irregular shape as well as size, and usually not 
more than two or three upon a patient. These last resemble bruises, and 
they may sometimes be such, received during the times of restlessness ; 
but ordinarily extravasations of this kind result entirely from the altered 
state of the blood. In New York, in the epidemic of 1872, they were 
common, but since this epidemic, in the thirty-six cases which I have 
observed, I have rarely seen either the reddish points or the extravasa- 
tions of blood. They were probably common in the epidemics in the 
first part of this century in this country, since the disease was designated 
by the name spotted fever by the American physicians who wrote upon 
it at that time. That they are unusual in the European epidemics at 
the present time, we infer from the fact that Yon Ziemssen expresses 
surprise that the disease should ever have been designated in America 
by such a title. 4. Herpes. This is common. It sometimes occurs 
as early as the second or third day, but in other instances not till toward 
the close of the first week or in the second. The number of herpetic 
eruptions varies from six or eight to clusters as large or larger than the 
hand. This cutaneous disease evidently has a nervous origin, the vesi- 
cles occurring in most instances on those parts of the surface which are 
supplied by branches of the fifth pair of nerves. Its most common 
seat is upon the lips, but occasionally it appears upon the cheek, upon 
and around the ears, and upon the scalp. Erythema and roseola fugi- 
tive skin eruptions occasionally appear, and in one instance in my prac- 
tice erysipelas occurred. During the first days the skin is frequently 
dry ; afterward perspirations are not unusual, and free perspirations 
sometimes occur, especially about the head, face, and neck. 

Urinary Organs. — In other forms of meningitis it is well known 
that the quantity of urine excreted is usually diminished, but in this 



THE SPECIAL SENSES. 377 

disease it is normal, and it may be more than normal. Polyuria has 
been noticed in different cases by various observers. Mosler observed 
a boy aged seven years, who had an excessive secretion of urine, 
which dated back to an attack of cerebro-spinal fever in his third year. 
The polyuria is probably due to injury of the nervous centre, since it 
is established by physiological experiment that irritation of the central 
end of the vagus, of certain parts of the cerebellum, and of the walls of 
the fourth ventricle, sometimes produces this effect. The urine occa- 
sionally contains a moderate amount of albumen, and in exceptional 
instances cylindrical casts and blood-corpuscles. 

Arthritic inflammation, apparently of a rheumatic character, has been 
occasionally observed. It is commonly slight, producing merely an 
cedematous appearance around one or more joints. Thus in one case 
which came under my notice, and which was subsequently fatal, the 
parents, who were poor, and were therefore without medical advice till 
the case was somewhat advanced, had already diagnosticated rheuma- 
tism on account of the puffiness which they had noticed around one of 
the wrists. 

The Special Senses. — Taste and smell are rarely affected, so far 
as is known, but it is possible that they are sometimes perverted, or 
even temporarily lost, during the time of greatest stupor. In one case, 
which I saw, the sense of smell was entirely lost in one nostril, and I 
do not know whether it was ever fully restored. 

The affections of the eye and ear are important and of frequent occur- 
rence. Strabismus is common. It may occur at any period of the 
fever, continuing a few hours or several days, and it may appear and 
disappear several times before convalescence is established ; occasionally 
it continues several weeks, after which the parallelism of the eyes is 
.gradually and fully restored. In other instances it is permanent. 
Thus in a boy of five years, whom I last saw three months after conva- 
lescence, there were still convergent strabismus of the right eye and 
double vision ; and in a boy of three years, convergent strabismus of 
the right eye remained when I examined him twelve months after the 
occurrence of the fever. 

Changes in the pupils are among the first and most noticeable of the 
initial symptoms, as I have already stated in describing the mode of 
commencement. These are dilatation, less frequently contraction, oscil- 
lation, inequality of size, feeble response to light, etc. Most patients 
present one or more of these abnormalities of the pupils, and they con- 
tinue during the first and second weeks, and gradually abate, if the 
course of the disease be favorable. Inflammatory hyperemia of the 
conjunctiva often occurs. It begins early, and now and then the con- 
junctivitis is so intense that considerable tumefaction of the lids results, 
with a free muco-purulent secretion. The false diagnosis has indeed 
been made of purulent ophthalmia, in cases in which this affection of 
the lids was early and severe. But such intense inflammation is quite 
exceptional. More frequently there is a uniform diffused redness of 
the conjunctiva, not so dusky as in typhus, and the injected vessels 
cannot be so readily distinguished as in that disease. 

In certain cases almost the whole eye (all indeed of the important 



378 CEREBRO-SPIXAL FEVER. 

constituents) becomes inflamed; the media grow cloudy, the iris dis- 
colored, and the pupils uneven and filled up with fibrinous exudation. 
The deep structures of the eye cannot, therefore, be readily explored 
by the ophthalmoscope, but they are observed to be adherent to each 
other, and covered by inflammatory exudation. They present a dusky 
red, or even a dark color, when the inflammation is recent. Exception- 
ally the cornea ulcerates and the eye bursts, with the loss of more or 
less of the liquids, and shrinking of the eye. " But ordinarily no 
ulceration occurs, and, as the patient convalesces, the oedema of the lids, 
hyperemia of the conjunctiva, the cloudiness of the cornea, and of the 
humors, gradually abate, and the exudation in the pupils is absorbed. 
The iris bulges forward, and the deep tissues of the eye, viewed through 
the vitreous humor, which before had a dusky red color from hvper- 
eemia, now present a dull white color. The lens itself, at first transpa- 
rent, after awhile becomes cataractous. Sight is lost totally and forever. 
This form of ophthalmia is sometimes rapidly developed, as in the fol- 
lowing example : 

On July 5, 1873, I was called to a boy, five years of age, who had 
reached the tenth day of cerebro-spinal fever without apparently any 
affection of the eyes, as both presented the normal appearance. On 
the following day the left eye was red and swollen from the inflamma- 
tion and chemosis, so that the lids could not be closed, and the media 
were cloudy. Death occurred on the same day. 

If the patient live the volume of the eye diminishes, as the inflamma- 
tion abates, to less than the normal size, even when there has been no 
rupture, and escape of the fluids, and divergent strabismus is apt to 
occur. Professor Knapp, whose description of the eye I have for the 
most part followed, says : " The nature of the eye affection is a puru- 
lent choroiditis, probably metastatic." Fortunately so general and 
destructive an inflammation of the eye as has been described above is 
comparatively rare. On the other hand, conjunctivitis of greater or 
less severity, and hyperemia of the optic disk, consequent upon the 
brain disease, are not unusual, but they subside, leaving the function 
of the organ unimpaired. " In some cases incurable blindness is 
noticed under the ophthalmoscopic picture of optic nerve atrophy, prob- 
ably the sequence of choked disk/' (Knapp.) 

Inflammation of the middle ear, of a mild grade, and subsiding with- 
out impairment of hearing, is common. The membrana tympani, during 
its continuance, presents a dull yellowish, and in places a reddish hue. 
Occasionally a more severe otitis media occurs, ending in suppuration, 
perforation of the membrana tympani, and otorrhcea, which ceases after 
a variable time. But otitis media is not the most severe of the affec- 
tions of the organs of hearing. Certain patients lose their hearing 
entirely and never regain it, and that, too, with little otalgia, otorrhoea. 
or other local symptoms by which so grave a result can be prognosti- 
cated. This loss of hearing does not occur at the same period of the 
disease in all cases. Some of those who become deaf are able to hear 
as they emerge from the stupor of the disease, but lose this function 
during convalescence, while the majority are observed to be deaf as 
soon as the stupor abates and full consciousness returns. 



THE SPECIAL SENSES. 379 

Two important facts have been observed in reference to the loss of 
hearing in these patients — to wit, it is bilateral and complete. When 
first observed it is, in some, as stated above, complete, but in others 
partial, and when partial it gradually increases till after some days or 
weeks, when it becomes complete. I have the records of ten cases of 
this loss of hearing, most of them occurring in my own practice in the 
epidemic of 1872, but a few of them detailed to me by the physicians 
who observed them in the same epidemic. According to these statis- 
tics about one in every ten patients became deaf, but in the milder 
form of cerebro-spinal meningitis which has prevailed since 1872, the 
proportionate number thus affected has been less among my patients, 
and the same may be said in reference to the loss of sight. One of 
the ten cases was a young lady, but the rest were children under the 
age of ten years. Professor Knapp has examined thirty-one cases. 
" In all," says he, "the deafness was bilateral, and with two excep- 
tions of faint perceptions of sound, complete. Among the twenty-nine 
cases of total deafness, there is only one who seemed to give some evi- 
dence of hearing afterward." The same author has recently informed me 
that further experience has confirmed his previous statement, that while 
the blindness produced by cerebro-spinal fever is in the majority of cases 
monolateral, only one case had come to his notice in which the deafness 
was on one side only. 

One theory attributes the loss of hearing to inflammatory lesions 
either at the centre of audition, within the brain, or in the course of 
the auditory nerves before they enter the auditory foramina. Thus 
Stille says: "This symptom appears to depend chiefly upon the pres- 
sure of the plastic exudation in which the nerves are embedded." The 
other theory attributes the loss of hearing to inflammatory disease of 
the ear, and especially of the labyrinth. Dr. Sanderson, who is an 
advocate of the latter theory, remarks as follows: "As regards the 
nature of the affection, there appears to be good reason for believing 
that, like the blindness observed under similar circumstances, and 
sometimes in the same cases, it is dependent on inflammatory changes 
in the organ of hearing itself. Dr. Klebs was kind enough to show me, 
in the pathological museum of the Charite at Berlin, a preparation of 
the internal ear of a soldier who had died of epidemic meningitis, com- 
plicated with deafness, in which fibrinous adhesions existed between the 
bones of the internal ear and the walls of the vestibule. Dr. Klebs 
stated that in the recent state the mucous lining of the vestibule was 
detached." In the case of a young woman who was deaf from the com- 
mencement and died on the eighth day, "both tympani were natural, 
but in the left membrana tympani was found a dense white thickening as 
large as a pin's-head. On the same side the lining membrane of the 
semicircular canal was distinctly thickened and loosed, and in the ante- 
rior canal there were semifluid purulent masses." Professor Knapp also 
states : " The nature of the ear disease is in* all probability a purulent 
inflammation of the labyrinth." According to him, no disease of the 
middle ear could cause such complete deafness ; and as evidence that 
the deafness is not due to central disease, Dr. Gruening obtained by 
electrization the normal reaction of the auditory nerve within the era- 



380 CEREBRO-SPINAL FEVER. 

nium. Moreover, if the lesion which destroys hearing be within the 
cranium, why are not the functions of the other cranial nerves also 
abolished ? Again, Drs. Keller and Lucse have in three post-mortem 
examinations found evidences of disease of the labyrinth. 

An argument in support of the former of these theories is the fact 
that the lesion which produces the deafness is not ordinarily attended 
by any marked subjective symptoms referable to the ear, as otalgia, etc. 
Again, the fact that the deafness is nearly always bilateral and simul- 
taneous in the two ears, comports better with the doctrine of a central 
lesion, than with that which locates the lesion within the ear. But the 
true theory can only be positively established by dissections, and, as we 
have seen, several post-mortem examinations have revealed inflamma- 
tory disease of the labyrinth in those who have died having this form of 
deafness ; while in no case, so far as I am aware, has the ear been found 
free from inflammatory lesions. Therefore the theory which ascribes 
the deafness to disease of the ear is much better established than the 
other, and must be accepted. Moreover, most of the aurists of this 
city, who have had excellent opportunities to examine these cases, 
believe in this theory. 

Nature. — The theory that cerebro-spinal fever is a local disease, 
occurring epidemically, was commonly held in the first part of this cen- 
tury, a theory which is now discarded. Job Wilson, in 1815, con- 
sidered it a form of influenza, and he could see no utility in drawing a 
distinction between spotted fever and influenza. We, at the present 
time, can see no resemblance between the two, except that both occur 
as epidemics. The theory that cerebro-spinal fever is a peculiar local 
disease occurring in epidemics is more plausible than that it is a form 
of influenza. Even Niemeyer says that it presents no symptoms except 
such as are referable to the local affection. But the evidence is strong 
that cerebro-spinal fever is a constitutional malady, with the meningitis 
as a local manifestation, just like measles with its bronchitis, or scarlet 
fever with its pharyngitis. The abrupt and severe commencement, 
unlike that of those forms of meningitis which are known to be strictly 
local, and the early blood change, as shown in certain cases by the 
appearance of the skin and extravasations under it, indicate a general 
disease. Constitutional diseases having prominent % local symptoms and 
lesions are usually regarded at first as local. It is only as time goes 
on, and they are more thoroughly studied and understood, and clinical 
observations multiply, that their constitutional nature is recognized, as 
for example at this late day the profession are beginning to recognize 
the constitutional nature of croupous pneumonitis. 

The theory that cerebro-spinal fever is a form of typhus once had 
advocates, but it is now so generally discarded, as untenable and absurd, 
that it would be a waste of time to consider the facts which differentiate 
the two maladies. Cerebro-spinal fever should, therefore, be considered 
as distinct from all other diseases, a malady sui generis, and in noso- 
logical writings it should be classified with those constitutional maladies 
which have specific causes. 

Although this disease ordinarily occurs in an epidemic form, in local- 
ities widely separated from each other, and after continuing a few weeks 



NATURE. 381 

or months, totally disappears, perhaps never to return, or not till after 
the lapse of years, nevertheless in certain localities it becomes estab- 
lished, so that it is proper to describe it as an; endemic, a fact to which 
we have already alluded as regards Xew York City. I do not know 
that it is endemic in any village or rural locality in this country, but it 
appears to be permanently established in certain of the large cities. 
The large cities, with their promiscuous population, foreigners and 
natives, their crowded tenement-houses, and many sources of insalubrity, 
furnish in an eminent degree the conditions which are favorable for the 
development and perpetuation of the specific principle. Those diseases 
which in the present state of our knowledge we have reason to believe 
are caused by microorganisms, we would expect to prevail most where 
domiciles are crowded and filthy, and systems are enervated by impure 
air, hardships, and privation. Hence in Xew York City, in the quar- 
ters of the poor, there is a constant succession of the infectious diseases 
of childhood. Often two or more of them occur simultaneously, and it 
is difficult to eradicate them or limit their extension when once they 
have obtained a foothold. The fact that a large city, with its tenement- 
house population, affords in an eminent degree the conditions in which 
the infectious diseases are developed and propagated, when once their 
specific principles have been introduced, is one of the chief causes of the 
large percentage of deaths among the city children. In Xew York what 
has been gained in saving life by the suppression of smallpox has been 
more than counterbalanced by the mortality produced by diphtheria and 
cerebro-spinal fever, both now to all appearance permanently established 
in our midst. The following table gives the number of deaths annually 
from cerebro-spinal fever in this city since the close of 1871 : 

Number 
of deaths. 

1872 782 

1873 290 

1874 158 

1875 146 

1876 127 

1877 116 

1878 97 

1879 108 

1880 170 

1881 461 

1882 238 

It is seen that the greatest mortality was in the first year after the 
introduction of the disease into the city, after which the number of 
deaths gradually diminished, year by year, till 1878, when the lowest 
mortality was reached. Since 1878 the mortality gradually increased 
till 1881, in which year the number of deaths was double that of any 
other year except 1872, it being half that of 1872. The weather and 
the season appear to exert little influence on the prevalence of this dis- 
ease now that it is established in the city. From the commencement of 
1882 till the end of May of the current year I find that it caused deaths 
in every week except one, and about the same number in each of the 
seventeen months embraced in this period. 

The mortuary reports of Philadelphia likewise show that cerebro- 



382 CEREBRO-SPINAL FEVER. 

spinal fever has remained in that city since its introduction in 1863, a 
period of twenty years, the annual deaths produced by it varying be- 
tween 30, the minimum, in 1869 and 1870, and 384, the maximum, in 
1864. In Providence, also, as appears from Dr. Snow's reports, cere- 
brospinal fever has caused annually more or fewer deaths since 1871. 
Therefore, we repeat, this fact may be added to the sum of our knowl- 
edge of this disease, that once gaining a lodgement, where the condi- 
tions are favorable for it, as in a large city, it may become established 
and remain there an indefinite time. 

Anatomical Characters. — I have notes of the post-mortem appear- 
ances in 76 cases, published chiefly in British and American journals; 
29 died within the first three days, 28 between the third and twenty-first 
days, and the duration of the remaining 11 was unknown. These 
records furnish the data for the following remarks : 

The blood undergoes changes which are due in part to the inflam- 
matory and in part to the constitutional and asthenic nature of the dis- 
ease. The proportion of fibrin is increased in cases that are not speedily 
fatal, as it ordinarily is in idiopathic inflammations. Analyses of the 
blood by Ames, Tourdes, and Maillot show a variable proportion of 
fibrin from 3.40 to more than six parts in 1000. In sthenic cases 
accompanied by a pretty general meningitis, cerebral and spinal, there 
is, after the fever has continued some days, the maximum amount of 
fibrin, while in the asthenic and suddenly fatal cases, with inflammation 
slight, or in its commencement, the fibrin is but little increased. The 
most common abnormal appearance of the blood observed at autopsies is 
a dark color with unusual fluidity and the presence of dark soft clots. 
Exceptionally bubbles of gas have been observed in the large vessels, 
and the cavities of the heart. An unusually dark color of the blood, 
small and soft dark clots, and the presence of gas-bubbles, when only a 
few hours have elapsed after death, indicate a malignant form of the dis- 
ease, in which the blood is early and profoundly altered. In certain 
cases this fluid is not so changed as to attract attention from its appear- 
ance. The points or patches of extravasated blood which are observed 
in and under the skin during life in some patients usually remain in the 
cadaver. When an incision is made through them the blood is seen to 
have been extravasated not only in the layers of the skin, but also in 
the subcutaneous connective tissue. Extravasations of small extent are 
also sometimes observed upon and in thoracic and abdominal organs. 

In those who die after a sickness of a few hours or days, namely, in 
the stage of acute inflammatory congestion, the cranial sinuses are found 
engorged with blood, and containing soft dark clots. The meninges 
enveloping the brain are also intensely hypersemic, in their entire extent 
in most cadavers; but in some cases the hyperemia is limited to a por- 
tion of the meninges, while other portions appear nearly normal. In 
those cases which end fatally within a few hours, this hyperemia is 
ordinarily the only lesion of the meninges; but if the case be more pro- 
tracted, serum and fibrin are soon exuded from the vessels into the 
meshes of the pia mater, and underneath this membrane, over the sur- 
face of the brain. Pus-cells also occur mixed with the fibrin, sometimes 
so few as to be discovered only with the microscope, but in other cases 



ANATOMICAL CHARACTERS. 383 

in such quantity as to be much in excess of the fibrin, and be readily 
detected by the naked eye. Pus, which in these cases probably consists 
of white blood-corpuscles which have escaped with the fibrin from the 
meningeal vessels, sometimes appears early in the attack. Thus Dr. 
Gordon 1 relates the history of a case in which death occurred after a 
sickness of five, hours, and a purulent greenish exudation had already 
occurred in places under the meninges. The exudation of fibrin also 
begins early. In a case of thirty hours' duration, published by Dr. 
William Frothingham, 2 and in another of one day's duration, published 
by Dr. Haverty, 3 exudation of fibrin had already occurred in and under 
the pia mater. The arachnoid soon loses its transparency and polish, 
and presents a cloudy appearance over a greater or less extent of its 
surface. This cloudiness is usually greatest along the course of the 
vessels in the sulci and depressions, and where the fibrinous exudation 
is greatest, but it occurs also where no such exudation is apparent to 
the naked eye. Dr. Gordon 4 describes a case of only eight hours' 
duration, in which the arachnoid was already opaque at the vertex, but 
of normal appearance at the base of the brain, though the vessels of the 
pia mater were everywhere greatly congested. 

The exudation — serous, fibrinous, and purulent — occurs as in other 
forms of meningitis, within the meshes of the pia mater, and underneath 
this membrane over the surface of the brain. The fibrin is raised from 
the surface of the brain with the meninges. It is most abundant in the 
inter-gyral spaces, around the course of the vessels, over and around the 
optic commissure, the pons Varolii, the cerebellum, medulla oblongata, 
and along the Sylvian fissures. It is most abundant in the depressions, 
where it sometimes has the thickness of -^ to ^ of an inch, but it often 
extends over the convolutions so as to conceal them from view. 

Most other forms of meningitis have a local cause, and are therefore 
limited to a small extent of the meninges, as, for example, meningitis 
from tubercles or caries of the petrous portion of the temporal bone, in 
both of which it is commonly limited to the base of the brain ; or from 
accidents, when the meningitis commonly occurs upon the side or sum- 
mit of the brain. The meningitis of cerebro-spinal fever, on the other 
hand, having a general or constitutional cause, occurs with nearly 
equal frequency upon all parts of the meningeal surface, except that it 
is perhaps most severe in the depressions, where the vascular supply is 
greatest. In cases of great severity the inflammatory exudation, fibrin- 
ous or purulent, or both, may cover nearly or quite the entire surface 
of the brain. Thus in the case of a negro, thirty-five years old, only 
four days sick, whose body was examined in Bellevue Hospital on May 
30, 1872, the record states that there was a purulent exudation over the 
entire surface of the cerebrum and cerebellum. The quantity of serous 
exudation varies according to the duration of the disease and amount of 
congestion. In some the quantity is so small as scarcely to attract 
attention, but in other instances, especially when the disease is protracted, 
it is large. In a case reported by Dr. Moorman, 5 it is stated that 

1 Dublin Quarterly Journ., 1866. 2 Amer. Med. Times, April 30, 1864. 

3 Dublin Quarterly Journ., 1867. * Ibid., 1866. 

6 American Journal of the Medical Sciences October, 1866. 



384 CEREBRO-SPIXAL FEVER. 

about three pints of turbid serum escaped from the cranial cavity in 
attempting to remove the brain ; but as there was no measurement the 
statement may be somewhat exaggerated. 

In those who die at an early stage of the attack, the vessels of the 
brain, like those of the meninges, are hyperaernic, so that numerous 
" puncta vasculosa " appear upon its incised surface. At a later period 
this hyperemia, like that of the meninges, may disappear. If there be 
much effusion of serum within the ventricles, and over the surface of the 
brain, the convolutions are liable to be flattened, and the pressure may 
be so great that the amount of blood circulating in the brain is reduced 
below the normal quantity. Thus in the case of a child of three years, 
who lived sixteen days, and was examined after death by Burclon-San- 
derson, the ventricles contained a large amount of turbid serum, and the 
brain-substance was everywhere pale and anaemic. 

Cerebral ramollissement occurs in certain cases. At one of the ex- 
aminations in Charity Hospital, the patient having been only three days 
sick, the brain was found much softened. The dissection was made 
seven hours after death, so that the softening could not have been the 
result of decomposition. At one of the post-mortem examinations in 
Bellevue Hospital, softening of the fornix, corpus callosum, and septum 
lucidum was observed, and in another, softening in the neighborhood of 
the subarachnoid space. In a case related by Dr. Moorman 1 it is 
stated that portions of the brain, medulla oblongata, and pons Varolii 
were softened. In a case observed by Dr. Upham softening of the 
superior portion of the left cerebral hemisphere had occurred. Occa- 
sionally the whole brain is somewhat softened. Burdon- Sanderson, 
Russell, and Githens each relate such a case. Moreover, the walls of 
the lateral ventricles are ordinarily more or less softened in fatal cases 
of cerebro-spinal fever, "as they are in the usual forms of meningitis. In 
rare instances the brain is oedematous, as in a case published by Dr. 
Hutchinson. 2 In this case the patient was only four clays sick, and the 
whole brain was oedematous, serum escaping from its incised surface. 

The ventricles contain liquid, in some patients transparent serum, in 
others serum turbid and containing flocculi of fibrin, or fibrin with pus. 
The liquids in the different ventricles, since they intercommunicate, are 
the same. The choroid plexus is either injected or it is infiltrated with 
fibrin and pus. With the abatement of the inflammation absorption 
commences. The serum, from its nature, is readily absorbed, and the 
pus and fibrin more slowly by fatty degeneration and liquefaction. 
Occasionally the serum remains, and chronic hydrocephalus results. 
An infant who contracted the disease at the age of five months, and 
appeared to be convalescent, had, two months subsequently, great prom- 
inence of the anterior fontanelle, and other symptoms which indicate 
the presence of a considerable amount of effusion within the cranium. 
In another case, one year afterward, examination showed the enlarge- 
ment of the head and prominence of the fontanelle which characterize 
chronic hydrocephalus. A boy of ten years, treated in Roosevelt Hos- 
pital in 1878, died three months after the commencement of cerebro- 

1 American Journal of the Medical Sciences, October 3 1866. 

2 Ibid., July, 1866. 



ANATOMICAL CHARACTERS. 385 

spinal fever. The records of the autopsy state: "Body a skeleton; 
brain, dura mater and pia mater appear normal, except a little thicken- 
ing of latter at base of brain; ventricles much enlarged and full of clear 
serum ; surface of walls of ventricles appears normal, but is soft ; spinal 
cord and membranes apparently normal; heart, lungs, stomach, and in- 
testines normal; liver congested; kidneys pale." In this case, there- 
fore, all the other lesions of the cerebro-spinal axis, except the serous 
effusion, had nearly disappeared. No post-mortem examinations, so far 
as I am aware, have yet revealed the state of the brain and its meninges 
in those who have had this malady at some former time and have fully 
recovered, whether there may not be some traces of it which are perma- 
nent, as opacity or adhesions. 

The remarks made in reference to the cerebral apply, for the most 
part, also, to the spinal meninges. There is at first intense hyperemia 
of the membranes, usually over the entire surface of the cord, soon fol- 
lowed by fibrinous, purulent, and serous -exudation in the meshes of the 
pia mater, and underneath this membrane. This exudation is some- 
times confined to a portion of the meninges, more frequently that cover- 
ing the posterior than anterior aspect of the cord, and when it is general 
it is ordinarily thicker posteriorly than anteriorly. In severe cases 
nearly or quite the entire spinal pia mater may be infiltrated by inflam- 
matory products. Thus in case of an infant that died of cerebro-spinal 
fever at the age of ten weeks, in the service of Dr. H. D. Chapin, in 
the out-door department at Bellevue, the entire spinal cord was covered 
by a fibrino-purulent exudation, except a space about six lines in extent 
upon the anterior surface. 

At the meeting of the New York Pathological Society, March 23, 
1881, Dr. G. L. Peabody presented the specimens from the body of a 
patient, aged nineteen years, who died on the tenth day of cerebro-spinal 
fever. The exudation extended over the base of the brain, both lobes of 
the cerebellum, and covered completely the cord to the cauda equina, being, 
as usual, thickest upon the posterior surface. In some patients the 
spinal meningitis is severe, while the cerebral is slight, so that the symp- 
toms referable to the spinal axis predominate, such as -pain in the back 
and limbs, and opisthotonos. The exudation may have the usual appear- 
ance of fibrin and pus, but it is sometimes greenish and sometimes blood- 
stained.* Small extravasations of blood also occur as a result of the 
hyperemia, and in one case related by Bur don- Sanderson it is stated that 
there was a layer of blood one-eighth of an inch thick over the whole 
cord below the bronchial swelling. In post-mortem examinations the 
central canal of the cord has usually been overlooked. Ziemssen relates 
a case, and Gordon another, in which it was dilated and filled with puru- 
lent fluid. The anatomical changes which have been observed in the 
cord itself have been injection of its vessels in recent cases, and occa- 
sional softening of portions. Thus in a case which was examined in 
Bellevue Hospital, April 13, 1872, it is stated that there was softening 
of the cprd in the upper part of the dorsal region. In most of the ex- 
aminations the only abnormal appearance detected in the cord was hyper- 
emia, but in a considerable proportion of cases the records state that the 
substance of the cord appeared normal. 

25 



386 OEREBEO-SPINAL FEVER. 

Professor Wm. H. Welch, of Johns Hopkins University, has recently 
communicated to me the following results of his examinations when 
curator to Bellevue Hospital: 

w> 1 have records of eight autopsies which I have made upon cases of 
cerebro-spinal meningitis, and in six cases I have examined, microscopic- 
ally, portions of the hardened brain and cord. Post-mortem rigidity is 
usually well marked and continues for a long time after death. Upon 
removal of the skull-cap, which is often hyperasmic, the dura mater 
appears tense, and usually more or less congested. The sinuses contain 
loose, dark red coagula, and some fluid blood. In one case I found a 
recently formed grayish-red ante-mortem thrombus in the left lateral sinus. 
The subdural space is usually free from inflammatory exudation, but 
occasionally a slight fibrino-purulent exudation is found on the outer 
surface of the arachnoid membrane. The pia mater is generally hyper- 
aemic, and frequently it contains small ecchymoses. An exudation is 
present in the subarachnoid spaces, over both the convexity and the 
base of the brain, most abundantly, as a rule, at the base. Over the 
convexity the exudation appears in the form of greenish-yellow streaks 
along the veins between the gyri. At the base the exudation accumu- 
lates in the subarachnoid cisterns, such as those of the Sylvian fissure, 
of the optic chiasm, of the intercrural space, of the under surface of the 
cerebellum, and along the basilar artery. The cranial nerve-trunks 
may be enveloped in a purulent exudate as they emerge from the brain. 
The fluid in the ventricles may or may not be increased in amount, but 
is usually turbid from admixture of pus-cells. The choroid plexuses 
are often swollen and opaque. 

" The substance of the brain is usually hyperasmic, and frequently 
contains punctate ecchymoses, which may occur in groups. Small foci 
of softening may be formed before death, but extensive diffuse softening, 
particularly that around dilated ventricles (hydrocephalic softening) is 
probably cadaveric, and due to imbibition of serum, although it may 
form within a short time after death. 

" The inflammatory exudation occupies likewise the subarachnoid 
space over the cord. The exudation may surround the posterior nerve- 
roots for a distance from the cord. Microscopic examination shows that 
the exudation is composed of serum, fibrin, pus-cells, and red blood- 
corpuscles. Usually the exudation is distinctly purulent, being of a 
greenish-yellow color, but it may be predominantly serous in character. 
The pus-cells are accumulated around the small veins and capillaries. 
I have found the ependyma of the fourth ventricle richly infiltrated with 
pus-cells, which here as well as elsewhere are probably emigrated white 
blood-corpuscles. The connective tissue cells of the pia-arachnoid mem- 
brane are swollen and granular. The lymph spaces around the blood- 
vessels in the cerebral cortex are often filled with pus-cells. The com- 
munication between these perivascular spaces and the subarachnoid spaces 
renders easy the passage of wandering cells from the pia mater into the 
cortex. There may also be found an increased number of lymphoid 
cells in the periganglionic spaces. In a similar manner the sheaths of 
the bloodvessels and the pial processes in the spinal cord may be in- 
vaded by pus-cells. 



PROGNOSIS. 387 

" In one of my cases the symptoms of the disease are said to have 
existed for only twelve hours before death. Here there was an excess of 
serum in the cerebral and spinal subarachnoid spaces. The serum was 
moderately turbid. The microscope showed a more abundant exudation 
of pus-cells than there appeared to be from the gross appearances. The 
substance of the brain was pale and ©edematous, nor was there marked 
congestion of the meninges." 

No constant or uniform lesions occur in the organs of the trunk, and 
those observed are not distinctive of this disease. Hypostatic conges- 
tion of the lungs, bronchitis, atelectasis, and broncho-pneumonia are 
common. Pleuritic, endocardial, and pericardial inflammations have 
occasionally been observed, but are rare. Effusion of serum, sometimes 
blood-stained, occasionally occurs in the pleural and other serous cavities. 
The auricles and ventricles of the heart, as already stated, contain more 
or less blood, with soft dark clots in the more malignant and rapidly 
fatal cases, but larger and firmer in those which have been more pro- 
tracted. The spleen is enlarged in less than half the patients. The 
absence of uniformity as regards the state of the spleen, the fact that in 
many it undergoes no appreciable change, is important, since this organ 
is so generally enlarged and softened in the infectious diseases. The 
stomach, intestines, and liver are sometimes more or less congested, but 
in other cases their appearance is normal. The agminate and solitary 
glands of the intestines have ordinarily been overlooked, but in certain 
cases they have been found prominent. The kidneys in some exhibit the 
lesions of nephritis. In one of the eight autopsies made by Professor 
Welch acute diffuse nephritis had been present, as shown by the state of 
the kidneys. In the case of a child of nine years, treated by Dr. F. A. 
Burrall, in the Presbyterian Hospital, the urine was very albuminous 
and the kidneys presented a fatty appearance. Anatomical changes in 
these organs, however, are not common, unless in slight degree, so that 
in most patients their function is fully and properly performed. 

Prognosis. — Cerebro-spinal fever is justly regarded as one of the 
most dangerous maladies of childhood. It is dreaded not only on ac- 
count of the great mortality which attends it, but on account also of its 
protracted course, the suffering which it causes, the possible permanent 
injury of the important organ which is chiefly involved, and the not 
infrequent irreparable damage which the eye and ear sustain. 

I have the records of the result in 52 cases which I attended or saw 
in consultation in the epidemic of 1872. Of these just one-half recov- 
ered. Sixteen of the twenty-six who died were hopelessly comatose 
within the first seven days, most of them dying within that time, and 
some even on the first and second days, while others of the sixteen lin- 
gered into the second week and died without any sign of returning 
consciousness. The remaining ten, who subsequently died, but did not 
become comatose in the first week, were nevertheless seriously sick 
from the first day, but their symptoms, though severe, were not such 
as necessarily indicated a fatal result, so that there was some expecta- 
tion of a favorable ending till near death, which occurred for the most 
part from asthenia. One succumbed to purpura hemorrhagica, the 
hemorrhages occurring from the mucous surfaces, and who died after a 



888 CEREBRO-SPINAL FEVER. 

sickness of more than two months, in a state of extreme emaciation and 
prostration. The twenty-six who recovered convalesced slowly and 
usually after many fluctuations. Their highest temperature and most 
severe and dangerous symptoms occurred in the first week. Most of 
them were several weeks under observation and treatment before they 
sufficiently recovered to be out of danger. The statistics of this epi- 
demic therefore show, and the same is true of other epidemics, that the 
first week is the time of greatest danger, and if no fatal symptoms are 
developed during this week recovery is probable with proper therapeutic 
measures and kind, intelligent, and efficient nursing, the latter of which 
is very important. 

Since the epidemic of 1872 I have treated, or seen in consultation, 
35 cases that I was able to follow to the close, most of them in the last 
four years. Of these 19 recovered and 16 died. Of the 16 fatal cases 
8 died in the first week, 5 in the second week, 1 on the twenty-fifth 
day, 1 on the thirty-first day, and 1 in the sixteenth week. This last 
patient, a boy of ten years, would, in my opinion, have recovered with 
better nursing;. His death occurred from large bedsores which ex- 
tended to the bones, produced, though attended by his mother, by lying 
a long time in one position on a hard bed, when he was too weak to 
move, and often with soiled bedclothes underneath him. 

There is probably no disease which falsifies the predictions of the 
physician more frequently than cerebro-spinal fever. This is due partly 
to the severity of the cerebral symptoms in the commencement, which, 
did they occur in other forms of meningitis with which he is more 
familiar, would justify an unfavorable prognosis, and partly to the 
remissions and exacerbations, the occurrence alternately of symptoms 
of apparent convalescence and recrudescence or relapse, which char- 
acterize the course of this malady. Grave initial symptoms, which 
may appear to have a fatal augury, are often followed by such a remis- 
sion that all danger seems past, and in a few hours later, perhaps, the 
symptoms are nearly or quite as grave as at first. 

Under the age of five years, and over that of thirty, the prognosis is 
less favorable than between these ages. An abrupt and violent com- 
mencement, profound stupor, convulsions, active delirium, and great 
elevation of temperature, are symptoms which should excite solicitude 
and render the prognosis guarded. If the temperature remain above 
105° death is probable, even with moderate stupor. Numerous and 
large petechial eruptions show a profoundly altered state of the blood, 
and are therefore a bad prognostic, and so is continued albuminuria, 
since it shows great blood change, or nephritis, while other organs than 
the kidneys are probably also involved. In one case, a boy, whom I 
examined nearly a year after the cerebro-spinal fever, the kidneys 
were still affected. He had anasarca of the face and extremities, with 
albuminuria. Chronic Bright's disease had occurred from the acute 
nephritis, which complicated cerebro-spinal fever. Profound stupor, 
though a dangerous symptom, is not necessarily fatal so long as the 
patient can be aroused to partial consciousness and the pupils are 
responsive to light ; so long as it does not pass into actual coma it is 



DIAGNOSIS. 389 

less dangerous than active or maniacal delirium, which is apt to even- 
tuate in this coma. 

A mild commencement, with general mildness of symptoms, as the 
ability to comprehend and answer questions, moderate pain and muscu- 
lar rigidity, some appetite, moderate emaciation, little vomiting, etc., 
justify a favorable prognosis, but even in such cases it should be guarded 
till convalescence is fully established. 

We may repeat and emphasize the important fact shown by the above 
statistics, that patients who live till the close of the second week with- 
out serious complications will probably recover. -The clanger after this 
period is, in most instances, from exhaustion and feeble action of the 
heart, resulting from the impaired nutrition and protracted course of 
the disease. 

Complications, which most frequently pertain to the lungs, increase 
greatly the gravity of many cases and contribute to the fatal ending. 
The fact that Webber, in his prize essay, describes a variety of cerebro- 
spinal fever which he designates pneumonic, and that those who make 
post-mortem examinations find that " oedema, hypostatic congestion of 
the lungs, bronchitis, atelectasis, and broncho-pneumonia, are extremely 
common lesions in cerebro-spinal meningitis" (Welch), indicates a 
source of danger in addition to that located in the cerebro-spinal 
system. One close observer of an epidemic writes : "In all the fatal 
cases which came under my notice, the most prominent symptoms which 
preceded death were those which indicate impairment and perversion of 
the respiratory functions. As the breathing became more hurried and 
difficult, the general depression became more intense, the pulse became 
weaker and quicker, and the temperature of the skin more elevated." 

Parenchymatous degeneration of the liver and kidneys is another 
serious complication. The kidneys are probably more frequently, and 
to a greater extent, diseased than the liver. Acute diffuse nephritis 
was present in one of the eight cases examined after death by Prof. 
Welch. In the Revue Medicate for June 3, 1882, M. Ernest Gandier 
published the case of a female who died comatose on the sixth day of 
cerebro-spinal fever. Examination of the urine had revealed the pres- 
ence of "retractile albumen of Prof. Bouchard, attributable to renal 
lesions, and non-retractile albumen, considered as an indication of some 
general infection of the system." Microscopic examination of the 
kidneys "showed considerable swelling and granular degeneration of 
the renal epithelial cells, with effusion of granular matter within the 
lumen of the tubules. We have seen from the case alluded to above 
that the renal complication may persist and become chronic. Those 
who fully recover often exhibit symptoms usually of a nervous char- 
acter, as irritability of disposition, headache, etc., for months after con- 
valescence is established. 

Diagnosis. — Cerebro-spinal fever, on account of the nature and 
severity of its symptoms and the suddenness of its onset, may be mis- 
taken for scarlet fever, and vice versa. In one instance, to my knowl- 
edge, this mistake was made. High febrile movement, vomiting, con- 
vulsions, and stupor, are common in the commencement of scarlet fever, 
and the same symptoms commonly usher in the severer forms of cere- 



390 • CEREBRO-SPINAL FEVER. 

bro-spinal fever. It will aid in diagnosis to ascertain whether there be 
redness of the fauces, for this is present in the commencement of scarlet 
fever, and in a few hours later the characteristic efflorescence appears 
on the skin. 

The diagnosis of cerebro-spinal fever from the common forms of 
meningitis is ordinarily not difficult, for while in the former the maxi- 
mum intensity of symptoms occurs in the first days, in the latter there 
is a gradual and progressive increase of symptoms, from a comparatively 
mild commencement. Moreover, cases of ordinary or sporadic menin- 
gitis occurring at the age when cerebro-spinal fever is most frequent, 
are commonly secondary, being due to tubercles, caries of the petrous 
portion of the temporal bone, or other lesion, and are therefore pre- 
ceded and accompanied by symptoms which are directly referable to 
the primary disease. We have seen how different it is in cerebro-spinal 
fever, which in most patients begins abruptly in a state of previous 
good health. Again, in cerebro-spinal fever, after the second or third 
day, hyperesthesia, retraction of the head, and other characteristic 
symptoms occur, which are either not present or are much less pro- 
nounced in ordinary meningitis. Some of the milder cases of cerebro- 
spinal fever might be mistaken for hysteria, but the pain in the head 
and elsewhere, muscular rigidity, and especially the occurrence of more 
or less febrile movement, enable us to make the diagnosis. Continued 
fever, typhus or typhoid, resembles cerebro-spinal fever in certain par- 
ticulars, but it lacks the muscular contraction and rigidity which char- 
acterize the latter. It does not usually begin so abruptly, with such 
severe symptoms, especially such severe headache, has less marked 
fluctuations, and a more definite duration. These facts, in connection 
with the character of the prevailing epidemics, will enable us to make 
the diagnosis. In one instance commencing retro-pharyngeal abscess, 
probably associated with vertebral caries, was at first mistaken by me 
for cerebro-spinal fever. The patient was an infant, had a tempera- 
ture of 104°, stiffness of the neck with some retraction of the head, and 
cried from pain when the head was brought forward. The speedy 
occurrence of two large abscesses in other parts of the system, difficult 
deglutition and noisy respiration, led to a digital exploration of the 
fauces, when the abscess was found and lanced. t 

Treatment. — Since in epidemics of cerebro-spinal fever cases are 
more frequent and severe where anti-hygienic conditions exist, it is evi- 
dent that measures looking to the removal of such conditions, measures 
designed to procure pure air in the domicile, wholesome diet, and a 
quiet and regular mode of life — in fine, measures designed to produce 
the highest degree of health — are of the first importance for the preven- 
tion of the disease. Cleanliness of the streets and areas, as well as 
apartments, perfect sewerage and drainage, the prompt removal of all 
refuse matter, avoidance of over-crowding ; in a word, the strict observ- 
ance of sanitary requirements in every particular, will, there can be 
little doubt from what we know of the causation and nature of cerebro- 
spinal fever, diminish the number and severity of the cases. The avoid- 
ance of fatigue and overwork, of mental excitement, the use of plain 
and wholesome diet, sufficient sleep, the utmost regularity in the mode 



CURATIVE TREATMENT. 391 

of life with the least possible exposure to depressing agencies, are the 
important preventive measures which should be recommended wherever 
an epidemic of cerebro-spinal fever is occurring. 

It is probable that the young man who, still weak from an attack of 
typhoid fever, applied himself closely to his business, of a perplexing 
nature, which had suffered from his absence, and in a few days was 
seized with headache and vomiting, and soon died of this malady, would 
have escaped by a more prolonged rest, and less mental excitement and 
worriment. It has seemed to me that those children whose cases are 
embraced in my statistics, that left home in the morning entirely well, 
and when engaged in their studies, subject to the noise and discipline 
of the public schools, which is often too severe and rigorous for sensi- 
tive children, were attacked with this disease, would probably have 
escaped in the quiet of their own homes. The girl that, failing of pro- 
motion in her school, returned home crying, and closely applied herself 
to her studies till she was compelled to desist by the severe headache 
which ushered in cerebro-spinal fever, perhaps would have remained 
well had her experiences in the school been more pleasant and less 
depressing. In a similar manner the two children that were attacked 
with cerebro-spinal fever immediately after mild punishments which 
they had received, but which produced mental excitement, perhaps 
would have escaped under less severe family discipline. 

The enjoining of a quiet and regular mode of life as a preventive 
measure, during the occurrence of an epidemic of cerebro-spinal fever, 
is not inconsistent with the theory that the cause is a microorganism. 
It is not unreasonable to suppose that the system may be more or less 
under the influence of the specific principle, that this principle may 
obtain lodgement in the blood or tissues without result until some 
exciting cause occurs which depresses the system and disturbs the func- 
tions, when the resisting power fails and cerebro-spinal fever appears ; 
just as those exposed to Asiatic cholera may remain well until some 
imprudence in the diet or the mode of life causes an outbreak of the 
malady. 

Curative Treatment. — In the commencement of cerebro-spinal 
fever, intense inflammatory congestion occurs of the cerebral and spinal 
meninges, and also to a certain extent of the brain and spinal cord. As 
regards treatment, the obvious indication is to reduce the hyperemia of 
the vessels as quickly as possible and subdue or diminish the inflamma- 
tion. For this purpose bags or bladders of ice should be immediately 
applied over the head, and to the nucha, and constantly retained there 
as long as there is no complaint of chilliness, no marked diminution of 
temperature, and the patient experiences some relief from the intense 
headache and other symptoms. Bran mixed with pounded ice produces 
a more uniform coldness and is sometimes more agreeable to the patient 
than the ice alone. The bag or bags should be about one-third full, so 
as to fit upon the head like a cap, and the nurse should be instructed 
to renew the ice as soon as it melts. In severe cases, with marked ele- 
vation of temperature, it is proper to apply cold over the dorsal and 
lumbar vertebrae, as well as upon the head and nucha. A hot mustard 
foot-bath or a general warm bath in those cases in which convulsions 



392 • CEREBROSPINAL FEVER. 

are present or threatening, or there is delirium or great agitation or 
severe peripheral pains, is also useful, since it has a calmative effect 
and acts as a derivative from the hyperaemic nerve-centres. One writer 
states that he obtained marked benefit in a case by immersing the body 
to the neck in hot water. 

The abstraction of blood, usually by leeches applied to the temples, 
behind the ears, or along the spine, has been employed, but even in the 
commencement of the present century, when it was customary to bleed 
generally and locally in the treatment of inflammatory and febrile dis- 
eases, a majority of the American physicians whose writings are extant 
discountenanced the use of such measures in the treatment of this dis- 
ease. Drs. Strong, Foot, and M iner, though under the influence of the 
Broussaian doctrine, were good observers, and they soon abandoned the 
use of the lancet and leeches in the treatment of these patients for more 
sustaining measures. Strong 1 states that certain physicians employed 
venesection as a means of relieving the internal congestions, but finding 
that the pulse became more frequent after a moderate loss of blood, 
they soon laid aside the lancet. Some experienced physicians of that 
period, however, continued to recommend and practise depletion, general 
as well as local, as, for example, Dr. Gallop, who treated many cases in 
Vermont, in the epidemic of 1811. 

Venesection in the treatment of cerebro-spinal fever is universally dis- 
carded at the present time in this country and in Europe, but some in- 
telligent physicians, as Sanderson and Niemeyer, approve of local bleed- 
ing in certain cases. It is, in my opinion, after examining the histories 
of many, cases, uncertain whether the abstraction of blood should ever 
be recommended, but if it be prescribed, it should be on the first day, 
when the hyperaemia is greatest, by the application of only a few leeches 
behind the ears, and never except when convulsions or coma are present 
or threatening, and the patient is robust. The fact should not be for- 
gotten that cerebro-spinal fever is in its nature asthenic and protracted, 
and that the intense inflammatory congestion of the nervous centres can 
ordinarily be relieved, if relieved at all, by the other measures recom- 
mended, which do not reduce the strength. The alarming symptoms 
which usher in an attack, the intense headache, restlessness, delirium, 
sometimes eclampsia or coma, seem to demand the most energetic treat- 
ment, and yet it is surprising to one who has his first experiences with 
this malady how patients under proper treatment, without the abstrac- 
tion of blood, emerge from an apparently almost hopeless state and ulti- 
mately recover. There may be total unconsciousness, the pupils dilated 
like rings and insensible to light, the head intensely hot, tonic convul- 
sions present .or alternating with frequent clonic convulsions, and yet 
these symptoms, which in any other disease would be regarded as suffi- 
cient to justify the prognosis of certain death, may gradually pass off 
toward the close of the first or in the second week, and the case after- 
ward progress favorably. In the New York epidemic ot 1872, pre- 
viously to which physicians of this city had no personal experience with 
cerebro-spinal fever, .many cases were pronounced hopeless which ulti- 
mately did well without abstraction of blood. In a case occurring in 

1 Medical and Physiological Eegister, 1811. 



CURATIVE TREATMENT 393 

the practice of Dr. Griswold the patient was comatose for three days, 
with pupils not responding, or but very feebly responding to light, but 
he recovered without the abstraction of blood, and with the remedies 
ordinarily employed. In a case which we will presently relate, in 
speaking of another local treatment, the patient was still insensible in the 
third week, with pupils greatly dilated and insensible to light, and yet 
recovered without losing blood. Such cases show that the most urgent 
symptoms, such as seem to indicate the prompt employment of leeches 
in order to reduce the meningeal hyperemia and the consecutive con- 
gestion of the nerve-centres, may be relieved and the patient recover 
without such depletion, and with the preservation of the blood, which is 
so much needed in the subsequent asthenic course of the malady. 

In only one case have I recommended the abstraction of blood, and 
this was so instructive that I will briefly relate it: A girl, four years of 
age, was seized on March 7, 1873, with vomiting, chilliness, and tremb- 
ling, followed by severe general clonic convulsions lasting about fifteen 
minutes; was semi-comatose; pulse 132, and a few hours later, 156; 
temperature 101^°; respiration 44; eyes closed, pupils moderately 
dilated and feebly responsive to light, dusky mottling of skin, constant 
tremulousness with twitching of limbs. Bromide of potassium was ad- 
ministered in hourly doses of four grains, ice applied to the head and 
nucha, and a hot mustard footbath followed by sinapisms to the nucha. 
On the following day, March 8th, she was partly conscious, when 
aroused, but immediately relapsed' into sleep, head retracted, bowels con- 
stipated; pulse 136; temperature 102°; vomits occasionally. It was 
thought proper, on account of the extreme stupor, to apply one leech to 
each temple and the bites trickled slowly nearly five hours. The other 
treatment was continued. On the 9th the pulse was 180, so feeble that 
it was counted with difficulty ; temperature 101 J°. The patient was 
evidently sinking. It was necessary to order whiskey in teaspoonful 
doses every two hours, with beef-tea and other most nutritious drinks. 
Evening, pulse 172, still feeble. March 10th, pulse 180, barely per- 
ceptible; great hyperesthesia; axillary temperature 100°; axes of 
eyes directed downward. After this the patient gradually rallied for a 
time, the pulse becoming stronger and less frequent, but death finally 
occurred after nine weeks in a state of extreme emaciation and exhaus- 
tion. Slight convulsions occurred in the last hours. 

It is seen that in the above case, which may be regarded as typical, 
the patient passed into a state of extreme prostration after the applica- 
tion of the leeches, so that for three days I did not believe that she would 
live from hour to hour, and death occurred after an illness of nine weeks, 
apparently from sheer exhaustion. Experience like this, which corre- 
sponds with that of most other observers, shows the necessity of preserv- 
ing the blood and thereby the strength, however urgent the initial symp- 
toms, inasmuch as cerebro-spinal fever in its subsequent course is attended 
by such marked asthenia. On May 3, 1878, a boy of ten years was 
admitted into one of our best hospitals, in the service of a prominent 
New York physician. It was stated that he had been four days sick with 
cerebro-spinal fever, and among other characteristic symptoms he had 
had delirium every night and on May 2d delirium in the daytime, which 



394 CEREBRO-SPIXAL FEVER 

had abated considerably after free epistaxis. In the hospital the appli- 
cation of ten leeches along the spine -was ordered, but it does not appear 
to have diminished the delirium or any other symptom, and on the fol- 
lowing day the pulse was so frequent and feeble that active stimulation 
by brandy was resorted to. He had three strong convulsions on May 
loth, which were relieved by ice to the head and nape of neck, and by 
six minims of Magendie's solution. Severe pains occurred at times in 
the back and limbs, and on the 29th, one month after the commence- 
ment of the disease, the same pain frequently recurring, twelve leeches 
were ordered to be applied to the spine. On June 2d the limbs were 
flexed and quite stiff, and the effort to move them w~as attended hy great 
pain. The pain in the back was also more constant, and in consequence 
sixteen leeches were applied to the spine. The next day there was no 
pain, but the patient was very stupid. On June 6th the records state 
that he was obviously losing strength day by day, that his emaciation 
was extreme and his aniemia very marked. But he had great vitality, 
and although he had strabismus, bedsores, incontinence of urine and 
feces, and extreme prostration, he lingered till August 1st. At the 
autopsy, "body, a skeleton; brain, dura mater, and pia mater appear 
normal, except a little thickening of latter at base of brain ; ventricles 
much enlarged and full of clear serum; surface of walls of ventricles 
looks normal but is soft; spinal cord and membranes appear normal to 
the naked eye." No disease was discovered in other organs, except that 
the liver appeared congested and the kidneys pale. It can scarcely be 
doubted that, although some temporary relief from the pain may have 
resulted to this patient by the repeated application of leeches, which 
diminished the meningeal hypersemia, yet his chances for ultimate 
recovery would have been far better without such depletion. Therefore 
the histories of cases show that the result of abstraction of blood has 
been unsatisfactory, on account of the asthenic nature and protracted 
course of cerebro-spinal fever, and it should be very rarely, if ever, 
recommended as a remedial agent. 

Some benefit is apparently derived from the application of stimulating 
and moderately irritating lotions along the spine. A liniment consist- 
ing of equal parts of camphorated oil and turpentine briskly applied by 
friction with flannel up and down the spine till redness is produced, 
appears to cause some alleviation of the suffering and it does not con- 
flict with the use of the ice-bag. Dr. TYilliam H. Sutton, of Dallas. 
Texas, has published the following interesting case, showing the benefit 
from stimulating and irritant applications over the spine made in an 
unusual manner. A child, aged three and one-half years, had been 
three weeks under treatment, through error of diagnosis, for supposed 
continued fever. When Dr. Sutton assumed charge of the case on 
November 20, 1877, the pupils were greatly dilated and insensible to 
light; features pallid and pinched; pulse 130; temperature 103°; 
patient totally unconscious. November 21st, morning temperature 
105°; pulse 140; evening temperature 101J ; pulse 120. Novem- 
ber 22d, morning temperature 106 J°; pulse 160; restless; evening 
temperature 105J°; pulse 120: had not slept except for moments for 
nearly two weeks. A strip of flannel saturated with turpentine was 



INTERNAL TREATMENT. 395 

placed over the spine from the neck to the sacrum, and a hot smoothing 
iron was run up and down it, and eight drops of the fluid extract of 
ergot were given every three hours. Dr. Sutton adds: "The father 
stated to me that as soon as the application was finished the child fell 
asleep, and slept several hours — the first for two weeks — and the fever 
rapidly declined. From this time he began to improve and gradually 
and fully recovered. The use of irritating applications over the spine 
in the treatment of cerebro-spinal fever has been long and favorably 
known, but the mode of applying it practised in the above case is 
novel. 

Internal Treatment. — It will aid in the selection of the proper 
remedies to recall to mind the pathological state which we know to be 
present from the many autopsies which have been recorded. We have 
seen that the largest mortality, and consequently the most dangerous 
period, is in the first days, when there is intense suddenly developed 
inflammatory congestion of the meninges, with more or less secondary 
hyperemia of the underlying brain and spinal cord, producing great 
headache, delirium, or somnolence, with exaggerated reflex irritability 
of the spinal cord, so that eclampsia is a common and fatal complication. 

Fortunately a remedy has been discovered in modern times, the 
bromide of potassium, which acts promptly and efficiently. It can be 
safely administered in large and frequent doses to the youngest child. 
It is quickly eliminated from the system through the kidneys and other 
emunctories in children, so as to prevent the occurrence of bromism, at 
least to the extent of causing any unpleasant consequences. It causes 
contraction of the minute vessels of the nervous centres so as to diminish 
the hyperemia, as shown by the experiments and observations of Dr. 
Putnam-Jacobi and others, and at the same time it diminishes, in a 
marked degree, the reflex irritability of the spinal cord, two most bene- 
ficial and important effects of its use in this disease. Many children by 
its timely employment are saved from the dangers of eclampsia, and by 
its sedative effect on the nervous system and contraccile action on the 
capillaries it probably diminishes the intensity of the inflammation and 
the amount of exudation. I usually prescribe it, as recommended by 
Dr. Squibb, dissolved in simple cold water. In ordinary cases not 
attended by eclampsia or marked symptoms which show that eclampsia 
is threatening, I usually prescribe at my first visit about four grains 
every two hours to a child of two years, who has the usual restlessness 
and apparent headache, and six grains to a child of five years. If 
eclampsia occur, the bromide should be given more frequently, as every 
five or ten minutes till it ceases. It is important to be able to determine 
when the quantity of the bromide administered should be diminished, 
and when its use should be discontinued. I have very rarely observed 
bromism in children, and never to the extent of doing any serious harm, 
though for many years I have administered it in large and frequent 
doses whenever the occasion seemed to require it, but the symptoms of 
bromism cannot readily be discriminated from those which may result 
from cerebro-spinal fever, such as muscular weakness, dilated pupils, with 
perhaps impaired vision, unsteady gait, nausea or vomiting, and ab- 
dominal pains. If the case progress favorably, frequent and large closes 



396 CEREBRO-SPINAL FEVER. 

should, in my opinion, be given only in the first week, after which this 
agent should be given at longer intervals, or in smaller doses. But 
during exacerbations, which are liable to occur from time to time till 
the patient is well on the way to recovery, the use of the bromide in full 
doses is again indicated till the urgent symptoms begin to abate. 

Ergot is another very important remedy. It is scarcely less useful 
than the bromide, from its known action in contracting the arterioles 
and diminishing the flow of arterial blood. The fluid extract, tincture, 
or wine of secale cornutum can be employed, or its active principle 
ergotine. In this city Squibb's fluid extract has been more used than 
any other preparation. I have commonly prescribed it except for 
patients old enough to take ergotine in the pill. The doses employed 
by different physicians vary greatly. Dr. William A. Thomson, Pro- 
fessor of Materia Medica in the New York University, has prescribed, 
so far as I am aware, the largest doses in the treatment of this disease, 
to wit, one teaspoonful of the fluid extract of secale cornutum every three 
hours to a boy of ten years in Roosevelt Hospital in 1878, with apparent 
benefit as regards the meningeal hyperaemia, although the case was fatal 
after the lapse of several months from asthenia. The alkaloid ergotine, 
to which the beneficial effects of the secale cornutum are due, may be 
given in the pill or in solution. In case of much irritability of the 
stomach it can be employed hypodermically, dissolved in water with 
glycerine. The efficacy of this agent is most marked during the first 
and second weeks, when the congestion of the nervous centres is greatest. 
At a more advanced stage, when there is less congestion and the clanger 
arises from the inflammatory products and structural changes, the time 
for the use of ergot is passed, or if it is still of some service it is less 
needed than at first and should be given less frequently. 

The severe headache and restlessness which attend many cases, re- 
quire the occasional use of an opiate, or the hydrate of chloral. Chloral 
in proper dose never fails to give quiet sleep, and it is supposed by 
some who have studied its therapeutic action that it diminishes the 
cerebral circulation. It is therefore an useful adjuvant to the bromide. 
Five grains usually suffice for a child of six to eight years. Chloral is 
especially useful in cases attended by eclampsia, or symptoms which 
threaten eclampsia, since it acts promptly and decidedly in diminishing 
reflex irritability. Formerly it was considered injudicious and unsafe 
to prescribe opiates in meningeal inflammation, since it was supposed 
that they increased the liability to coma, but experience shows that they 
are sometimes very useful in this disease when administered in small or 
moderate doses, and without the risk which was once supposed to be in- 
curred by their use. The thirty-second part of a grain of morphia 
administered at intervals of some hours was sufficient to relieve the 
suffering of one of my patients at the age of six years. 

Quinia apparently does not exert any marked controlling effect on the 
course of cerebro-spinal fever or its symptoms, although the paroxysmal 
character of the severe pains in many patients suggests the use of this 
agent as aii antiperiodic. It was frequently prescribed by New York 
physicians in the epidemic of 1872, but I believe 'that the opinion was 
unanimous that it was not the proper remedy. I have prescribed it in 



INTERNAL TREATMENT. 397 

large and small doses, in one instance giving fifteen grains to a child of 
thirteen years, but do not know that I have derived any benefit from its 
use in this malady. 

When the acute stage has abated, measures designed to remove the 
serum which sometimes remains, constituting a hydrocephalus, are indi- 
cated. For this purpose the iodide of potassium is probably more useful 
than any other agent. It is administered by some physicians early, 
along with the bromide, as they have been in the habit of treating other 
forms of meningitis. I have prescribed it with the bromide, and alone 
when the bromide was discontinued, but whether it produces a sorbe- 
facient effect in this disease seems to me doubtful. 

The result depends to a great extent on the nursing. The skill of 
the physician may be thwarted and the life of the patient lost by in- 
efficient nursing. No other disease more urgently requires kind, intelli- 
gent, and constant attendance night and day on the part of the nurses. 
Not only should the medicines and nutriment be given punctually and 
regularly, but the great restlessness of the patient in the first days 
requires constant readjusting of the ice-bags, and during the long period 
of convalescence the utmost care is required to remove at once the excre- 
tions in order to prevent bedsores, and to give the proper amount and 
kind of nutriment to prevent the emaciation and weakness from which 
many perish. Among my cases are those who owed their recovery largely 
to the untiring devotion of mothers. The one that died of bedsores I 
have little doubt would have recovered had the nursing been such as 
some of the others received. 

The diet, from the beginning to the end of the malady, should be the 
most nutritious, and such as is easily digested. It is necessary to give 
it in the liquid form, unless in mild cases in which the appetite may not 
be entirely lost. It is proper to aid the digestion by pepsine prepara- 
tions. Nutritive enemata, consisting of beef-tea, or Leube's extract of 
beef, milk, and brandy, aid in averting the fatal prostration in protracted 
cases. After the acute stage has passed by and the meningeal hyper- 
emia has abated, the alcoholic compounds in moderate doses, which in 
the beginning would be very injurious, may now be useful, administered 
regularly by the mouth. The room should be dark, well ventilated, 
and quiet. All sympathizing friends who are not required in the nurs- 
ing should be excluded. I know no other disease in which this is so 
necessary, for mental excitement may produce dangerous aggravation 
of symptoms. Recently a young lady, "to whom I made one visit in 
consultation, and whose recovery seemed probable, was allowed to receive 
the visit of a young gentleman. Immediately after his departure her 
headache was intensified, the symptoms became generally aggravated, 
and the result in a few days was fatal. 



398 ACUTE RHEUMATISM 



CHAPTER Y. 

ACUTE KHEUMATISM. 

Rheumatism is a constitutional disease with a local manifestation, 
to wit, inflammation of the sero-fibrous tissues, chiefly in and around 
the articulations, but occasionally in the heart. It was formerly sup- 
posed to be rare in children, but more accurate observations show that 
it is scarcely less common during childhood than in adult life. In young 
patients, especially under the age of six or eight years, it is frequently 
overlooked, for the articular inflammations in such patients are com- 
monly slight. In the last fifteen years, during my connection with the 
children's class in the Bureau for the Relief of the Outdoor Poor, I have 
examined many children with rheumatism or the cardiac lesions result- 
ing from rheumatism, and ordinarily I have found that few joints were 
affected, and that there had been but little swelling of them, or redness, 
and that the patients were almost never confined to bed, or even to the 
sitting posture, but had been able to walk about, though with restraint 
and complaint of pain or soreness. The parents in many instances sup- 
posed that their children were suffering from "growing pains," as they 
designated them. At the same time, with this mildness of symptoms, 
the heart was becoming seriously and permanently crippled, by endo- 
carditis. Those who have attended my clinics will recollect that on 
some days as many as three or four children with cardiac lesions have 
been present whose histories showed an overlooked rheumatism of this 
mild type. Cases like the following are very common among the city 
poor: 

In January, 1871, a little girl, three years old, was presented, having 
distinct aortic direct, and mitral regurgitant murmurs. The mother 
was not aware that she had had rheumatism, but at the age of twenty 
months she had for several days pretty active febrile symptoms, which 
the physician attributed to some other ailment. In April, 1871, another 
girl, of the same age, was brought to the clinic, having a distinct mitral 
regurgitant murmur. The mother stated that she had been well till a 
month previously, when she was confined to her bed for a few days, 
having a high fever. She was attended by a homoeopathic physician, 
and the exact character of her sickness the mother was not able to state. 
Further medical advice was sought, as the child remained delicate, though 
her health was better than at first. There can be little doubt that the 
obscure fever in this case was rheumatic. In another child treated 
elsewhere, not old enough to relate the subjective symptoms, there was, 
in addition to an intense fever, evident pain in one foot or leg, when the 
limb was moved. Still, the nature of the disease was not diagnosticated 
till some time after recovery, when a valvular murmur was accidentally 
discovered. Such histories, which are not rare show that rheumatism 



SYMPTOMS. 399 

often occurs in young children, even infants, and they inculcate the 
important practical lesson, that the disease at this age may be so ob- 
scure, or latent, as to be overlooked even by good diagnosticians. 

Some observers, meeting cases of valvular disease in children, without 
the history of rheumatism, have concluded that rheumatism is not the 
chief cause of endocarditis at this age j 1 but the explanation which I 
have given seems to me more in consonance with the facts. Scarlet 
fever not infrequently causes endocarditis, but this exanthem seldom 
occurs without detection, and it has been as often absent as has rheu- 
matism from the histories as given by the parents of young children 
with valvular disease, whom I have examined. Moreover, the endo- 
carditis of scarlet fever is in many cases associated with, if it do not 
result from, scarlatinous rheumatism. 

Rheumatism in children is primary or secondary. The secondary 
form occurs chiefly in the declining stage of scarlet fever and variola. 
It is stated, also, to occur occasionally in newborn infants during epi- 
demics of puerperal fever, but I have not observed such cases. 

Causes. — An inherited rheumatic diathesis is universally recognized 
as an important predisposing cause of this disease, so that it frequently 
occurs in different members of the same family. When the family 
history shows a strong predisposition to rheumatism, it occurs in the 
child from a slight exciting cause ; if no such predisposition exist, it 
only occurs through unusual circumstances of exposure. The ordinary 
exciting cause is the same as in most idiopathic inflammations, to wit, 
exposure to cold ; but a strong rheumatic diathesis appears to be suffi- 
cient in itself to produce an outbreak of the disease. Children who 
have had one attack are especially liable to another. 

The morbific principle in the blood which produces the phenomena 
and lesions of rheumatism, is supposed to be lactic acid, a theory which 
originated with Prout, and is strengthened rather than weakened by 
observations since his day. According to this theory, lactic acid sustains 
the same causative relation to acute rheumatism as uric acid to gout, and, 
as Prof. Austin Flint states, it receives support from the fact that the 
lactic acid treatment of diabetes may produce rheumatic inflammation 
of the joints. 

Symptoms. — The commencement of acute idiopathic rheumatism is 
in most cases sudden ; occasionally fever, and a degree of soreness or 
stiffness, precede the articular affection for a few hours or days. The 
inflammation, slight at first, increases gradually, attaining its maximum 
intensity within one or two days. The joint is painful, red, hot, and 
swollen. The swelling is due to inflammatory oedema of the tissues 
surrounding the joint and effusion within the joint. As in all inflam- 
mations, the vascularity of the parts involved is increased, the synovial 
membrane loses, more or less, its lustre, and the effused fluid, which is 
mainly serum, has been found, in most of the cases in which an oppor- 
tunity was presented to examine it, to contain, like the pleuritic exuda- 
tion, a few globules of pus. Rarely, in a reduced state of the system, 
so much pus is produced within the joint as to constitute a true abscess, 
and rarely also fibrin is exuded, producing a rubbing sensation when 

1 Dr. A. Steffen, Jahrbuch fur Kinderh., 1870. 



400 ACUTE RHEUMATISM. 

the joint is moved, and endangering permanent adhesion of the articular 
surfaces. Fortunately, however, in the vast majority of cases, the sub- 
stance exuded both without and within the joint is mainly serum, and 
hence the rapid subsidence of the swelling when the inflammation ceases. 
The pain is commonly not severe when the child is quiet, but it is 
greatly increased if the joint be pressed or the limb moved. 

The joints of the extremities are most frequently the seat of rheu- 
matic inflammation, but occasionally those of the trunk, as the inter- 
vertebral, the symphysis pubis, etc., are involved. As the inflammation 
abates in the articulations first affected, it reappears in others, unless 
the materies morbi have been eliminated from the system. It is seldom 
that more than two or three of the joints are in a state of active inflam- 
mation at the same time. 

The temperature in acute rheumatism is elevated two or three degrees 
above that of health, and the pulse varies from 120 to 140, its frequency 
depending on the age of the patient, as well as the gravity of the dis- 
ease. Perspiration is a common symptom. The appetite is impaired, 
the tongue slightly coated, and the bowels constipated. The watery 
element in the urine is diminished, as in most febrile diseases, and there 
is not a corresponding reduction in the solid elements, so that the urine 
is rendered more dense, and its specific gravity is high. The amount of 
urea and coloring matter excreted from the kidneys is augmented during 
the active period of rheumatism, and the urine, when it cools, deposits 
urates. In ordinary cases there is no prominent symptom referable to 
the nervous system, with the exception of pain in the affected joint. 

Acute rheumatism, if only the articulations were involved, would be 
a disease of little danger, however painful, but unfortunately in its 
proneness to produce specific inflammation of the sero-fibrous tissues, the 
heart frequently becomes involved, less frequently the lungs and pleura, 
and in rare instances the cerebral or spinal meninges. Endocarditis is 
the most frequent of the heart inflammations occurring in rheumatism ; 
pericarditis, though less common, is not infrequent, while in rare in- 
stances myocarditis occurs, usually associated with the other inflamma- 
tions. Endocarditis is limited to the left side of the heart, and seldom 
continues long without engaging the valves, aortic or mitral, or both, 
causing their infiltration, fibroid degeneration, with consequent thick- 
ening, and sometimes adhesion. The valvular lesion thus produced is 
in most instances permanent, so impairing the action of the valves as 
to obstruct in greater or less degree the flow of blood through the orifice 
and allow its regurgitation. 

The mitral valve is more frequently affected than the aortic, at least 
bruits produced by this lesion are more frequent in the mitral than 
aortic orifice, and when they are heard in both orifices they are commonly 
loudest in the mitral. This fact, noticed by different observers, I have 
repeatedly verified by observations in this city. 

While the articular affections pertain to the clinical history of rheu- 
matism, the internal inflammation, whether of the heart, lungs, pleura, 
or meninges, though similar as regards its pathological character, is 
properly considered as a complication. Acute rheumatism is so fre- 
quently complicated by one or the other of these affections, that any 



PROGNOSIS 



401 



Fig. 26. 



disproportionate severity in the general symptoms, as compared with 
the inflammation of the joints, or any sudden and unexpected increase 
in the symptoms, should always lead the physician to examine thor- 
oughly the condition of those organs which are most frequently affected. 

Inflammatory complications occur, as a rule, during the active period 
of rheumatism, when the inflammation is passing from joint to joint. 
If the general symptoms begin to improve, and no new joints are in- 
volved, the liability to complications is greatly diminished. Secondary 
rheumatism, occurring in most instances in connection with certain 
eruptive fevers, especially scarlatina, commonly affects only a few joints, 
often only one or two, as the wrist, and, though painful, is attended 
by slight swelling and redness. 

Duration — Prognosis. — With proper treatment and without com- 
plication the febrile action in a few days begins to abate, and the dis- 
ease commonly terminates within two weeks Its duration is ordinarily 
shorter than in rheumatism of the adult. Fluctuations, however, are 
liable to occur. The disease may appear to be abating, and the articular 
inflammations nearly cease, when they return for a time, often without 
new exposure and without appreciable cause. The prognosis, even when 
cardiac inflammation has supervened, is in most cases favorable, except 
so far as the lesion resulting from this inflammation is concerned, which 
being permanent may entail much subsequent suffering, and occasion 
death after months or years. Indeed, w T hat is most to be dreaded in 
cases of acute rheumatism is valvular disease or 
pericardial adhesion with its remoter consequences, 
namely, hypertrophy of heart, congestion and 
oedema of lungs, dropsies, etc. 

Secondary rheumatism occurring in scarlet fever 
is sometimes also complicated with or, rather coex- 
ists w T ith, cardiac inflammation, pleuritis, or pneu- 
monitis, rendering the prognosis more unfavorable. 

In rare instances the acute symptoms of rheu- 
matism abate, but the joints remain stiff and more 
or less swollen, and painful when moved. The 
acute has lapsed into a subacute or chronic rheu- 
matism. Such a case, represented in the accom- 
panying figure, was brought to the children's class 
in the Outdoor Department at Bellevue Hospital, 
in February, 1871. E. EL, a female, 3J years 
old, had intermittent fever from the age of nine 
to fifteen months. From this time she remained 
well till the age of two years, when she was taken 
with acute rheumatism, commencing in her ankles 
and extending to other joints. The knee and hip 
joints on both sides have only partially recovered 
their mobility, and both legs and both thighs are 
permanently flexed, so that the gait is slow and unsteady. It is im- 
possible to straighten either limb without causing great pain, and 
attempts to straighten the thigh produce the arch in the back very 
similar to that in coxalgia. 

26 




402 ACUTE RHEUMATISM. 

Diagnosis . — This is not difficult in ordinary cases, if a proper exam- 
ination be made. In the commencement, if the affection of the joints 
be slight, rheumatism might be mistaken for remittent, typhoid, one of 
the eruptive fevers, or meningitis ; but, on careful examination, tender- 
ness of one or more of the articulations will be observed, and probably 
some swelling. This tenderness is readily distinguished from the hyper- 
esthesia which is common in the first stage of the essential fevers, and 
which is observed when pressure is made upon the chest or abdomen as 
well as upon the limbs, and is more marked between the joints than in 
them. Any doubt which may at first exist, whether the patient may 
not have one of those diseases, is soon dispelled, since their clinical 
history presents notable differences from that of rheumatism. 

I have known scrofulous arthritis, or scrofulous ostitis near the joint, 
present so close a resemblance to acute rheumatism as to be at first 
mistaken for it. In one instance this inflammation commenced nearly 
simultaneously in three joints, rendering the diagnosis at first very diffi- 
cult. But scrofulous inflammation, as well as that from pyaemia, can be 
diagnosticated from rheumatic disease of the joints, by its greater per- 
sistence, less induration and symmetry in the swelling, and by the his- 
tory of the case. Chronic rheumatism may produce deformity similar 
to that from chronic scrofulous inflammation, as in the case mentioned 
above, but the rheumatic history, number of joints affected, bilateral 
character of the inflammation, good general health, etc., are sufficient to 
establish a clear diagnosis, when the disease has been observed for some 
days. 

Treatment. — The theory of the pathology of a disease determines 
the mode of treatment, and the theory that rheumatism is due to an acid 
in the blood, probably lactic, though not established, has been widely 
received, and has led to the extensive employment of alkalies, as tartrate 
of sodium and potassium, acetate of potassium, etc. The alkaline treat- 
ment apparently materially abridges the duration of acute rheumatism ; 
but lately a new remedy, namely, salicylic acid, has been found to act 
almost as a specific in a large proportion of cases, quickly relieving the 
pain, and subduing the inflammation, so that a few days suffice to effect 
a cure. Speedy cure of this malady is urgently demanded, on account 
of the imminent peril to the heart. Children are very liable to the 
cardiac complication. Although salicylic acid frequently causes the dis- 
appearance of all symptoms within a week, they are apt to reappear 
unless the medicine be continued in occasional doses for some days sub- 
sequently, as I have had opportunity to observe. It should be prescribed 
with an alkali, as in the following formula, which is similar to one em- 
ployed in the Outdoor Department at Bellevue : 

R. — Acid, salicylic .^ij-i'j- 

Potas. acetat. . . . . . . ^s*. 

Glycerinaa . . . . . . ^j. 

Aquae q. s. ad ^ v. — Misce. 

Give one teaspoonful every three hours to a child of six years. 

A new remedy, producing useful therapeutic effects, is apt to be pre- 
scribed at first for too many distinct pathological states, till finally its 
use is restricted to such conditions as it is found to relieve. Salicylic 



TREATMENT. 403 

acid has undergone this trial, and, while it has been rejected as a remedy 
for the infectious diseases, it is recognized as the most useful of all 
remedies for the disease which we are now considering. An occasional 
opiate, as Dover's powder, may also be needed between the doses of the 
acid. 

An eligible mode of prescribing salicylic acid is in the salicylate of 
sodium, which is very soluble and not so unpleasant to the taste as 
salicylic acid in combination with most other bases. It is used more 
than any other preparation of salicylic acid in New York, and much 
more than any other remedy for the treatment of acute rheumatism, and 
ordinarily with a good result. It may be administered in a formula 
like the following : 

]&. — Sodii salicylat. gij. 

Syr. bal. tolut. . . . . . . . . 5ij. 

Aquae . . . . . . . . . ■ 5 v j- 

Dose, a dessertspoonful every two or three hours to a child of five years. 

Recently I employ the following formula, since the oil of wintergreen 
contains a considerable amount of salicylic acid : 

R.--01. gaultheriae ^j. 

Sodii salicylat. . . . . . . . ziij. 

Syr. simplic. ........ ^iij- 

Aquae gvj. — Misce. 

Dose, a dessertspoonful to a child of five years. 

During the declining period of rheumatism and in convalescence qui- 
nine or some preparation of cinchona should be employed and the above 
medicine given less often. This tonic does indeed appear to exert a 
beneficial effect on the course of rheumatism, and it is employed by 
some judicious and experienced physicians from the commencement. 

If there be a high temperature and a quick pulse, quinine adminis- 
tered in an occasional large dose will be found very useful. Three to 
five grains may be given to a child of five years. 

Rheumatism impoverishes the blood, and the patient often begins 
to present an anaemic appearance, when he requires iron in addition 
to the vegetable tonic. The citrate of iron and quinine may then be 
employed. 

Secondary rheumatism requires sustaining treatment from the first. 
Such cases ordinarily do well without anti-rheumatic treatment, with 
the general supporting measures employed for the primary disease. 

Pneumonitis complicating rheumatism is best treated by moderate 
counter-irritation and emollient poultices, and the internal use of car- 
bonate of ammonium or quinine. In pericarditis or endocarditis, if, as 
is commonly the case, the movements of the heart be accelerated, aconite 
or the tincture or infusion of digitalis, is demanded to the extent of re- 
ducing the number of pulsations to near the normal frequency. A 
child of six years can take three drops of the tincture or a large tea- 
spoonful of the infusion, to be repeated, if necessary, in three hours, 
till the required reduction of the pulse is effected. Patients often 
experience relief, by the use of this agent, from- the palpitation and 
dyspnoea consequent upon the embarrassed movements of the heart. 
If the heart disease be severe and pulse feeble, quinine is also useful. 



404 ERYSIPELAS. 

The patient should be kept quiet, in a room of uniform temperature, 
and not exposed to draughts of air. By such precautions the danger 
of complications is greatly diminished. Repellant applications, as cold 
or irritants, should not be applied to the joints, so long as the disease is 
acute, for they also increase the danger of complications. The affected 
joints should be enveloped in flannel or cotton, and the pain, if intense, 
may be diminished by applying flannel wrung out of warm water. If 
the disease become subacute or chronic, if the urates have disappeared 
from the urine, and the inflammation cease to pass from joint to joint, 
the tincture of iodine, or moderately stimulating embrocations, applied 
to the joints, involve no danger and are useful. 



CHAPTEE YI. 



ERYSIPELAS. 



The term erysipelas is applied to a constitutional or blood disease, 
which is characterized by inflammation of the skin and subcutaneous 
connective tissue, and by a tendency to spread. It is accompanied by 
pungent and pricking heat, swelling, and subcutaneous infiltration. 

In rare instances, in young infants, an inflammation which has been 
designated erysipelas occurs in and around the umbilicus. It com- 
mences about the time of the detachment of the umbilical cord, and is ac- 
companied by redness of the skin and tumefaction, with induration of the 
connective tissue surrounding the umbilicus. It usually causes ulcera- 
tion of the umbilical fossa, and, in fatal cases, pus is sometimes found 
in the umbilical vessels. This disease does not show any tendency to 
spread ; the diameter of the inflamed surface is not more than three or 
four inches, with the umbilicus at the centre. It is generally fatal ; 
but two favorable cases have been reported to me, in one of which there 
was considerable ulceration, and after recovery a firm cicatrix occupied 
the site of the umbilicus. The most reasonable view is that this disease 
is primarily an inflammation of the umbilical fossa and vessels, induced 
by uncleanliness, cachexia, or other cause. It lacks the distinguishing 
feature of erysipelatous inflammations, namely, the tendency to spread, 
and I shall, therefore, take no further notice of it in this connection. 
(See Diseases of the Umbilicus.) 

Erysipelas occasionally occurs in childhood ; the cases which are met 
in this period present nearly the same features, and pursue nearly the 
same course, as in the adult. In infancy, erysipelas is a common dis- 
ease, and the following remarks relate chiefly to erysipelas occurring 
in this period of life. They are based on data derived mainly from the 
records of cases which occurred in this city, some in my own practice, 



ERYSIPELAS. 



405 



and others in the practice of physicians known to be good observers. 
The points of chief interest in forty-one cases are embraced in the 
following table : 

Cases of Infantile Erysipelas. 





GO 


Age. 


Point OF 
Commencement 


Parts Affected. 


Duration. 


Result. 


1 


M. 


5 months. 


Right kuee. 


Entire surface, except face and scalp. | 5 weeks and 

3 days. 


Recovered. 


2 


BL 


2 years. 


Left knee. 


From a little above the knee to the 7 days, 
ankle. 


Recovered. 


3 


M. 


10 months. 


Elbow. 


Whole arm and forearm. 


Recovered. 


4 


F. 


20 months. 


Below right knee 


Entire leg, thigh, and trunk to the; 7 days, 
umbilicus. 


Recovered. 


5 


F. 


9 months 


Vulva. 


Abdomen, chest, and all the extremi- 18 days. 

ties 
Both lower extremities, abdomen ta 6 days. 


Recovered. 


6 


M. 


9 days. 


Genitals. 


Died. 










the umbilicus. 






7 


F. 


1 year. 


Vulva. 


Entire surface, except face. 


6 weeks. 


Recovered. 


8 


F - 


weeks. 


At or near the 
ear 


Forehead and side of face. 


1 week. 


Died in tetanic 
spasms. 


9 




9 months. 


Epigastric region 


Trunk and lower extremities. 


2 weeks. 


Died in tetanic 
spasms. 


10 


F. 


10 months. 


At angle of 
mouth. 


Entire face and scalp. 


10 days. 


Recovered. 


11 


F. 


4 weeks. 


Vulva. 


Entire surface, except face. 


3 weeks. 


Died. 


12 


F. 


3 mouths. 


Vulva. 


Surface of abdomen to umbilicus and 
right lower extremity. 


2 weeks. 


Recovered. 


13 


F. 


4 to 5 mos. 


Vulva. 


All "the limbs and trunk, except the 3 to 4 weeks 


Died. 










chest. 






14 


F. 


5 months. 


From syphilitic 
sores around 
anus. 


Trunk and both lower extremities. 






15 


F ' 


3 months. 


Vulva. 


Entire trunk and both upper ex- 
tremities. 


3 weeks. 


Recovered. 


1€ 


31. 


8 months. 


Face near nos- 
trils 


Entire trunk and both upper ex- 
tremities 


About 2 
weeks. 


Recovered. 


17 


F 


4 months. 


Vulva. 


Entire trunk and all the extremities. 


1 week. 


Died. 


18 


F. 


7 mouths 


Knee. 


A portion of trunk and both lower ex- 3 weeks. 


Recovered. 










tremities. 






10 


F. 


6 months. 


Near the ear. 


Entire face and forehead. 


10 days. 


Recovered. 


20 


31. 


7 day 8. 


Left eyelid. 


Left side of face. 


3 da vs. 


Died. 


21 


31 


14 days. 


Genitals 


Extended to knee, over abdomen to' 4 days. 


Died. 










the chest. 






22 


31. 


3 months. 


Under the chin. 


Chin, left cheek, neck, left side of 
trunk, left thigh and leg . 






23 


F 


28 months. 


Right shoulder. 


Arm and forearm. 


lday. 


Died in con- 
vulsions. 


24 


F 


3 or 4 days. 


Vulva. 


Body and all the limbs. 


12 days. 


Died. 


25 


r 


3>^ mos. 


Under left ear. 


Neck, chest, and arms. 


About 2 
weeks. 


Died. 


20 




7 months. 


Below right knee 


Trunk, neck, and head, and all the 

limbs. 
Both thighs, and nearly entire trunk. 


2 weeks. 


Died comatose. 


27 


F 


6 months 


Vulva. 


3 days. 


Died comatose. 


28 


31. 


19 months. 


Near point of 
vaccination. 


Shoulder, arm, and forearm. 


21 days. 


Recovered. 


20 


M. 


4 months. 


Near point of 
A-aceination. 


Chest, and both upper limbs. 


2 weeks. 


Recovered. 


30 


F. 


2 months. 


Near vaccine 


Trunk, and all the limbs. 10 days. 


Died. 








vesicle. 








31 




3 to 4 mos. 


Near vaccine 
vesicle. 


Arm, forearm, and shoulder on one 
side. 


2 to 3 weeks 


Died. 


32 


F. 


4 months. 


Near vaccine 
vesicle 


Arm, forearm, and trunk. 


2 months. 


Died. 


33 


M. 


2 months. 


Near vaccine 
vesicle . 


Nearly entire surface. 


1 week. 


Died with 
peritonitis. 


34 


M. 


5% mos. 


Near point of 
vaccination 


Arm and forearm. 




Recovered. 


30 


M. 


2% mos. 


Near point of 
vaccination. 


Arm. 


7 days. 


Died probably 
of peritonitis 


3C 


M. 


8 months. 


Near vaccine- 
vesicle. 


Arm and forearm. 


17 days. 


Died. 


37 




5 months. 


Left foot. 


Leg, thigh, and lower part of trunk. 


2 weeks. 


Died with 

pneumonitis 
Recovered. 


38 




5 weeks. 


At one ear. 


Entire surface. 


2 weeks. 


30 




2 months 


Left leg. 


Trunk, and all the limbs. 


2 weeks. 


Recovered. 


4>: 




4 months. 


Near point of 
vaccination. 


Trunk, and all the limbs. 


2 weeks. 


Died. 


41 


M. 


14 months. 


Face. 


Trunk, and all the limbs. 


4 weeks. 


Recovered. 



406 ERYSIPELAS. 

Age. — Of the above cases, 27 were under the age of six months ; 9 
from six months to twelve, and only 5 above the latter age. A large 
majority, therefore, of cases of infantile erysipelas occur in the first 
year of life. 

Point of Commencement. — In 58 cases in which I have ascer- 
tained the point of commencement, it was in 13 cases the vulva, 17 the 
arm after vaccination, 7 the leg, 6 the face, 3 the male genital organs, 
3 at or near the ear, 1 the elbow, 1 the shoulder, 1 the nates, 1 the 
foot. In the adult, idiopathic erysipelas commonly commences upon 
the face, and affects only the face, ears, forehead, and scalp. On the 
other hand, in infantile erysipelas, statistics show that the rash com- 
mences upon the face only in a small proportion of cases, one in nine, 
and that it rarely extends to the face when it commences in other parts. 

Causes. — In erysipelas the first departure from the healthy state 
occurs in the blood, or the system generally. This undergoes certain 
changes which predispose to erysipelas, or are sufficient in themselves to 
give rise to it. Among the causes which produce this state of system, 
uncleanliness, residence in damp, dark, and crowded apartments, and 
defective alimentation, hold a principal place. Hence this disease is 
more common in the poor quarters of a city than in the country, and 
in dispensary and hospital than in family practice. 

In a large proportion of cases there is a local exciting cause of in- 
fantile erysipelas, to wit, an irritation or inflammation at some point, 
generally trivial, but which is sufficient to develop the disease in the 
system already prepared for it. It commonly commences at or near 
a simple ecthymatous or impetiginous eruption, around burns or sup- 
purating sores or syphilitic eruptions ; it frequently commences, as 
is seen by the above table, near the point of vaccination immediately 
after vaccination, or when the pock is developed, or again when it has 
run its course and been detached. In a considerable proportion of 
cases it begins at a point where the skin is thin and delicate, or 
where it unites with a mucous surface, probably from some uncleanli- 
ness or irritation of those parts. Thus, I have records of cases in which 
it commenced at the external ear, commissure of the mouth, and at the 
vulva. Indeed, the frequency with which it commences at the vulva 
renders female infants more liable to it than males. In some instances 
erysipelas begins without any local exciting causes, upon smooth and 
sound skin, even when there are sores upon various parts of the surface. 

Vaccination, as an exciting cause of erysipelas, demands particular 
notice. Often, doubtless, it is the inflammation which necessarily arises 
from the cut or the vesicle, which operates as an exciting cause of the 
erysipelatous affection, and not any deleterious property contained in 
the virus which is employed, so that an equal degree of inflammation 
occurring in any other way, as from a burn, would be attended by a 
like result. But facts show that the virus itself occasionally contains a 
latent noxious principle, which, introduced into the system, operates as 
a cause of erysipelas. Thus, a little girl was vaccinated by me in 
November, 1860, and about the time when the vesicle began to fill she 
was seized with severe inflammation of the fauces, attended by tumefac- 
tion and infiltration of the submucous connective tissue. The inflam- 



CAUSES. 407 

mation rapidly subsided, and within a week from its commencement the 
throat affection had nearly or quite disappeared. I now believe that 
the disease of the fauces was erysipelatous, although it was not suspected 
at the time to have this character. 

As the girl was otherwise healthy, and the vaccine vesicle passed 
through its usual stages, and presented the usual appearance, the scab 
was employed six weeks afterward to vaccinate two infants. Within 
twenty-four hours after vaccination both these infants were seized with 
high fever, ushering in severe erysipelas, commencing in one around 
the point of vaccination, and in the other around syphilitic sores near 
the anus. In the former case the erysipelatous rash extended from the 
shoulder over the entire limb, and was obstinate, twice reappearing, and 
extending over the same surface ; in the latter (a mulatto child) it 
extended over both lower extremities and a considerable part of the 
trunk, when the case passed into the hands of another physician, and 
the result is not known. The instrument with which the vaccinations 
were performed was clean. The vaccine disease did not appear in either 
of these cases. 

Again, a well-known physician of this city vaccinated three infants, 
one his own (No. 32 of the table), with part of a scab which had been 
pronounced good, but was taken from a child that he had not seen, and 
with whose state he was not familiar. These infants were all affected 
with erysipelas from the vaccination, his own dying. He had taken 
the precaution to rub the lancet on his boot before using it. Another 
physician of his city has informed me that he vaccinated two children 
in the same family with a scab, with all the precautions that he ever 
had used, and both were soon after affected with erysipelas of a severe 
form, extending from the point of vaccination ; the vaccine disease did 
not appear. I have heard of no case in which the vaccine lymph gave 
rise to erysipelas, and probably it rarely or never does. ' In the lymph 
there is no admixture of foreign substances, whereas in the scab there is 
a large proportion of animal matter. 

There is a form of erysipelas which occurs in the infant immediately 
after birth, and which is sometimes met in private practice, but is most 
frequently observed as an epidemic in lying-in-wards. It is associated 
with severe, and commonly fatal, puerperal or septic fever, or erysipelas 
of the mother. This form of erysipelas is fatal, almost without excep- 
tion, and its contagiousness is generally admitted by those who have 
had opportunity to observe cases. 

A case showing the relation of erysipelas in the newly born infant to 
disease of the mother occurred in the practice of Dr. Learning, of this 
city. A woman gave birth to a healthy infant, on the 27th of July, 
1860. A few days subsequently she was seized with a chill, followed 
by erysipelas, commencing on the thighs, and terminating fatally 
August 17th. As no autopsy was allowed, the state of the internal 
organs was not ascertained. A few days before her death the same 
disease commenced on the infant. It extended around the neck, upon 
the ears, down the arms, and terminated fatally August 24th. But 
erysipelas in the newborn infant, occurring in connection with erysipelas 
in the mother, is more rare than its occurrence with puerperal fever. 



408 ERYSIPELAS. 

The records of lying-in asylums furnish many examples of epidemics 
of puerperal fever, in which the infants of affected mothers perish of 
erysipelas. 

The late Dr. Folsom, of this city, furnished me the following sketch 
of cases which occurred in his practice and that of his partner : " About 
the year 1840, being then in practice in New Bedford, Mass., I was called 
to visit a man who complained of pain in the knee: The next morning 
he was easier, but the following evening his symptoms grew worse, and 
as I was engaged in a case of obstetrics, my partner, Dr. E. C, now 
dead, visited him. At my call, next morning, I unexpectedly found 
the patient dying. The disease was obscure, and at the autopsy next 
day no lesion was discovered. In making the examination, Dr. C. 
pricked his finger, and experiencing little inconvenience from it at first, 
he attended a case of confinement on the following morning. A few 
hours subsequently he was taken sick, and I took charge of the lady, 
who died in three days, having the tumid abdomen and symptoms of 
childbed fever. The infant of the patient was seized, when two days 
old, with erysipelas, appearing on the face and in spots on the trunk 
and limbs, and terminating fatally in one day. Dr. C.'s finger became 
swollen and painful, and the lymphatics of the forearm and arm became 
inflamed, presenting red lines, and the axillary glands suppurated. 
Though feverish and much prostrated, there was no appearance of ery- 
sipelas in his case. In about two weeks he resumed practice, and as at 
that time physicians in this country were not fully aware of the danger 
of communicating puerperal fever, he attended two, three, or four 
obstetrical cases each week, until the number reached fifteen. All the 
mothers died with symptoms of metro-peritonitis, and all the infants had 
erysipelas, commencing on the face or some part of the body, generally 
on the second or third day after birth, and in all terminating fatally 
within a week. This sad record was finally ended by the doctor's tem- 
porarily retiring from practice." 

Dr. Condie 1 says: "Erysipelas of infants very commonly occurs 
during the prevalence of epidemic puerperal fever. Children of 
mothers who become affected with the fever are often born with ery- 
sipelatous inflammation ; others are attacked almost immediately after 
birth. Whether, in these cases, the disease is to be referred to a 
morbid matter applied to the skin in the womb", or to the same epi- 
demic or endemic influence which gives rise to the disease of the 
parent, it is difficult to say. According to M. Trousseau, infantile 
erysipelas is principally observed when puerperal fever prevails in the 
wards of the lying-in hospitals at Paris." In private practice it is rare 
that we meet erysipelas of the infant associated with erysipelas or with 
puerperal fever in the mother. Some of the oldest physicians of this 
city, with whom I have conversed, and who are engaged in extensive 
general practice, state that they have never met a case in which there 
was this relation. Cases like those observed by Drs. Folsom and Learn- 
ing only occur when epidemic erysipelas or puerperal fever is prevailing. 

According to Ziegler, erysipelas is produced by a micrococcus which 

1 Treatise on Diseases of Children. 



SYMPTOMS. 409 

enters the lymphatics and spreads chiefly by them. They are found in 
immense masses, or swarms, in the lymphatics, and from them they 
spread into the tissues, where they excite inflammation and often tissue 
necrosis. 

Premoxitory Symptoms. — Infantile erysipelas in certain cases has 
no premonitory stage, or, if present, it escapes notice. In other in- 
stances there are well-marked precursory symptoms, as drowsiness, or 
restlessness, febrile movement, oppressed respiration, with perhaps 
vomiting, and starting or twitching of the limbs. In Cases 28 and 37 
of the table, which occurred in my practice, the febrile movement, rest- 
lessness, and oppressed respiration were so great for three days before 
the appearance of the eruption, as to cause much anxiety. In the 
adult, pharyngitis often precedes the occurrence of the rash upon the 
skin. The same inflammation may be present in the premonitory 
period of infantile erysipelas, as well as daring the period of erysipe- 
latous eruption. The hurried and difficult respiration which is present 
in the commencement of some cases, is probably due to an erysipelatous 
turgescence of the bronchial mucous membrane. 

Symptoms. — The patient with this disease is usually restless, in con- 
sequence of the burning pain which accompanies the eruption. In 
severe cases there is little sleep, night or day, except from medicine. 
The sleep is short, and is often interrupted by sudden starting or 
twitching of the limbs. Convulsions may occur, but are not common. 

Febrile movement is constant, and is proportionate to the extent and 
gravity of the erysipelas. I have notes of cases in which the pulse was 
more than 200 per minute, although other symptoms did not indicate 
immediate danger. The skin not affected by erysipelas is dry and hot, 
though not possessing the pungent heat of the inflamed portion ; face 
often flushed; tongue moist, and covered with a light fur; stomach 
usually retentive. The state of the bowels varies ; sometimes they are 
regular ; sometimes variable, while in other cases the stools are green, 
and more frequent than natural. I have records relating to the state 
of the bowels in twenty cases, as follows : in seven, regular ; in nine, 
loose; in two, constipated; in one, constipated, then loose; and in one, 
constipated, then regular. Diarrhoea, when present, is usually mild, 
requiring little or no treatment. The erysipelatous redness is not in all 
cases so pronounced as in the adult, but otherwise there is nothing 
peculiar in its appearance. In feeble infants, with an impoverished 
state of the blood, its color is pink, instead of the deep red which char- 
acterizes the inflammation in the robust. Points of vesication may 
occur where the inflammation is most severe, as in the adult, and subse- 
quently the same desquamation and oedema. 

If the infant be debilitated, there is great danger of the formation of 
abscesses, around which the inflammation lingers after it has disappeared 
from every other part of the body. Sometimes also, in very young 
infants gangrene occurs, especially in the genital organs in the male. 
Several of these cases have been related to me, all under the age of a 
month or six weeks, and all fatal. Occasionally the sloughing is so 
great as to denude the testicle. A noteworthy feature of erysipelas in 
infants is its proneness to return. When it has been progressively 



410 ERYSIPELAS. 

subsiding, and hope is entertained of its speedy disappearance, it not 
infrequently is suddenly relighted from some unknown cause, travelling 
again over the same, or parts of the same surface. In one case the 
disease, arising from vaccination, extended three times over the arm and 
forearm ; and in another case, a second time over both legs and a con- 
siderable part of the trunk. 

The internal inflammations which most frequent complicate erysipelas, 
and give rise to symptoms which are superadded to those pertaining to 
the erysipelas, are pharyngitis and peritonitis ; and more rarely broncho- 
pneumonia or enteritis. In a case which I examined after death, in the 
Nursery and Child's Hospital, and in which the erysipelatous inflam- 
mation having extended over the abdomen, the lesions of peritonitis 
were present, it appeared, from the thinness of the abdominal walls, 
that the inflammation had extended through the parietes from the ex- 
ternal to the internal surface. 

Prognosis. — Erysipelas is much more fatal in infancy than in adult 
life. In the death statistics of this city for three years, I find eighty 
deaths from erysipelas of infants under the age of one year, to eighty- 
three deaths from this disease above that age. Age greatly influences 
the prognosis. Infants under the age of three weeks usually die ; from 
the age of three weeks to six months the result is doubtful ; while above 
the age of six months a majority recover with correct treatment. It will 
be seen by the foregoing table that seven infants under the age of six 
weeks had erysipelas, and six died ; from the age of six weeks to six 
months, six recovered and nine died ; and above the age of six months, 
nine recovered and four died. 

With the exception of a case of the so-called umbilical erysipelas, the 
youngest child who recovered, of whom I have obtained information, was 
three weeks old. In this case the rash extended nearly over the entire 
surface, beginning with the face. Case 38 of the table, treated by my- 
self, was very similar as regards the extent of the erysipelatous eruption 
and the result. This infant was five weeks old. 

It is scarcely necessary to state that erysipelas is more favorable when 
it affects the limbs than when it invades the head, neck, or body ; when 
it spreads slowly than rapidly; when it is superficial than when phleg- 
monous. In those cases in which the^ connective tissue is much in- 
volved, the infant is not always safe after the disease has run its course ; 
he sometimes dies exhausted from the discharge of abscesses; I have 
records of two such cases. 

Duration. — In sixteen cases that recovered, the erysipelas terminated 
within the first week in two, the second week in six, the third week in 
five, fourth week in one, and in two cases it lasted five and six weeks. 
The average duration was fifteen days. In nineteen fatal cases, ten 
died within the first week, five the second week, three the third week, 
and one in the fourth week. The average duration of fatal cases was 
about ten days. 

Modes of Death. — Death occurs in different ways ; in clonic or 
tonic convulsions followed by coma, from exhaustion, and from internal 
inflammation ; that from exhaustion being probably the most common. 

Pathological Anatomy/. — The blood doubtless in this disease under- 



TREATMENT. 411 

goes certain pathological alterations previously to the occurrence of the 
eruption, but the exact changes are not known. Our knowledge of the 
morbid anatomy of erysipelas relates chiefly to the local affections, 
which, with the exception of the inflammation of the skin, are not con- 
stant, and may, therefore, be regarded as complications. The cutaneous 
inflammation affects all the structures of the skin, and in greater or less 
degree also the subcutaneous connective tissue. The inflammation is 
accompanied by more or less serous effusion or oedema. 

The not infrequent occurrence of peritonitis in connection with ery- 
sipelas has long been known. In Heberden's Epitome Morborum 
Puer ilium, the anatomical character of erysipelas is expressed in one 
sentence: " When the body has been opened after death, the intestines 
have been found glued together and covered with coagulable lymph." 
Since Heberden's time, nearly all who have written on diseases of infancy 
and childhood have mentioned peritonitis as one of the most common 
complications. Underwood says: "Upon examining several bodies 
after death, the contents of the body have frequently been found glued 
together and their surface covered with inflammatory exudation, exactly 
similar to that of women who have died of puerperal fever." Similar 
remarks in reference to the frequency of peritonitis in this disease are 
made by recent writers. 

The statistics in reference to erysipelas as well as peritonitis show 
that in infants in hospital practice, and in those affected by erysipelas 
during epidemics of puerperal fever, peritonitis is a not infrequent com- 
plication. On the other hand, as we commonly meet cases of infantile 
erysipelas occurring sporadically in private practice, abdominal dis- 
tention and tenderness are not sufficient to indicate peritonitis In 
only one of the cases embraced in the foregoing table was a post-mortem 
examination made, and in that there had been no peritonitis. The 
occurrence of pharyngitis in connection with erysipelas has been already 
mentioned. 

Enteritis has been alluded to as another complication in infants. 
Diarrhoea has been stated to be a symptom in certain cases, and it has 
been found to be dependent on enteritis of a mild grade. Billard made 
post-mortem examinations of sixteen infants who died of erysipelas, and 
"found in two gastro-enteritis, in ten enteritis, in three pneumonia 
complicated with enteritis and cerebral congestion, and in one pleuro- 
pneumonia." 

Treatment. — On this side of the Atlantic great uniformity prevails 
as regards the treatment of erysipelas. Sustaining measures are pre- 
scribed, and the tincture of the chloride of iron is the tonic generally 
preferred. Whatever the intensity of the febrile reaction and the stage 
of the disease, if there be no intestinal complication, ferruginous or other 
tonics should be administered. The largest doses of the tincture of the 
chloride of iron given in any of the cases in the above table w r ere in case 
No. 4, namely, ten drops every two hours, and this patient recovered in 
seven days from a pretty severe attack. Probably, however, nothing is 
gained by such large doses, and they may irritate the intestinal surface, 
and increase the liability to enteritis, which, we have seen, complicates 
a certain proportion of cases. Four drops may be given every three 



412 ERYSIPELAS. 

hours to a child from one to two years of age. Instead of the iron, or in 
addition to it, one of the preparations of cinchona may be prescribed. 
Beef-tea, and wine-whey or other alcoholic stimulant, are required. 

The depressing measures recommended by certain writers cannot be 
too strongly censured. One author says: " We should endeavor from 
the first to allay the inflammation of the skin by energetic treatment. 
. . . Local abstraction of blood, by means of one or two leeches 
applied at the circumference of the primary seat of the erysipelas, should 
be put in force, provided the power of the constitution of the children 
permits." Such treatment may explain one of this author's aphorisms, 
namely, the erysipelas of infants is a fatal disease. 

Local treatment may be employed to arrest the extension of the in- 
flammation, but the result in most cases is not encouraging. Solid 
nitrate of silver was employed in two cases of which I have records, 
and in both the result was pernicious. Troublesome sores were pro- 
duced, from which blood escaped, and in one of the cases, at least, 
death was attributed by the parents to this treatment, rather than to 
the disease. 

Tincture of iodine is a better remedy for arresting the extension of 
erysipelas. It should be applied from the margin of the inflammation, 
over the sound skin, to the distance of about two inches. It may be in- 
effectual, but it does not produce any unfavorable result. Soothing 
applications, like rye flour, or a lotion of sugar of lead, may be made to 
the inflamed surface, as in erysipelas of the adult. I prefer, however, 
for local treatment, the constant application of vaseline or glycerine and 
water, to which carbolic acid is added — one to ten. 



PART III 



SECTION I. 

DISEASES OF THE CEREBROSPINAL SYSTEM. 

Diseases of the brain and spinal cord are less frequent than those 
of the respiratory and digestive systems. They are also less amenable 
to treatment, and are much more fatal. They largely increase the 
aggregate of deaths. They contrast with the diseases of the other 
systems in their greater relative frequency in infancy and childhood 
than in adult life. This is explained, as regards the brain, by the rapid 
development and active molecular change in this organ in early life, its 
great impressibility by the emotions, and the thinness of the covering 
which protects it from external agencies. 

Some of the most interesting of the cerebro-spinal diseases which are 
to engage our attention, are peculiar to early life, as tetanus infantum. 
The diseases of this system also contrast with other local affections in 
their greater obscurity, especially in their commencement; for, while 
maladies of the thorax can be readily ascertained by auscultation and 
percussion, or those of the abdomen by the nature of the evacuations or 
the degree of tenderness or distention, our means of conducting exami- 
nation through the bony encasement of the cerebro-spinal axis are 
meagre and unsatisfactory. The condition of the brain and spinal cord 
must be determined, chiefly, by the study of symptoms, and not by 
direct examination. The condition of the anterior fontanelle in young 
infants, however, enables us to determine the presence or absence of 
active congestion of the brain. If there be an excess of arterial blood, 
it is convex. Prominence of the fontanelle is common in inflammatory 
and febrile diseases, and is a sign of considerable diagnostic and prog- 
nostic value. 

Within a few years, the ophthalmoscope has been employed as a 
means of diagnosis in cerebral diseases, and although the employment 
of this instrument for such purpose is but recent, enough has been 
elicited to prove its value as an aid in determining the state of the 
brain. Prof. H. D. Noyes remarks on this subject: . . . "The 
argument for making ophthalmoscopic examination in all cases of brain 
disease, becomes irresistible. Indeed, a moment's reflection would lead 
to this conclusion without any considerations drawn from pathology. 
The optic nerve is only an outlying portion of the brain ; its extremity 
is fully exposed to view. Situated within about two inches of the brain, 
it is the only nervje in the body which we can inspect ; it contains 

(413) 



414 DISEASES OF THE CER EBRO - SPIN AL SYSTEM. 

bloodvessels which communicate directly with the intracranial circula- 
tion. We thus come into relation with the cerebrum, by continuity of 
nerve-structure and also of bloodvessels." 

Structural changes in the optic nerve and retina have been discov- 
ered by means of the ophthalmoscope in meningitis, hydrocephalus, 
phlebitis of the sinuses, apoplexy, etc. Among the lesions which have 
been observed by this instrument, are hyperaeruia, more or less opacity 
and tumefaction of the optic nerve, engorgement of the vessels of the 
retina, with serous or sero-fibrinous exudation and ecchymotic points. 
In certain protracted diseases, as chronic hydrocephalus, in which dim- 
ness or loss of sight occurs, the ophthalmoscope discloses a state of atrophy 
of the optic nerve. Heretofore this instrument has been chiefly em- 
ployed by oculists, but as it comes into more general use, there can be 
little doubt that it will be recognized as an important aid in the diag- 
nosis of obscure cerebral diseases. 

Still, with all possible aids to diagnosis, the obscurity which attends 
the invasion of many of the cerebro-spinal diseases must be acknowl- 
edged. To the hasty and careless physician, their symptoms are often 
deceptive. Careful weighing of the phenomena, and thorough and pro- 
tracted examination, are requisite in order to insure correct diagnosis 
and proper treatment. Some of the cerebro-spinal affections are, in 
reality, sequelae of other diseases, as, for example, spurious hydrocepha- 
lus; and some are, strictly speaking, only symptoms, as convulsions; 
but, on account of their importance, and because they require special 
treatment, it is proper to consider them as diseases per se. 

The brain presents certain peculiarities in infancy and childhood. In 
the foetus, while the other organs are well formed, the brain, especially 
its cerebral portion, is still diffluent, and at birth it has so little con- 
sistence that it must be handled carefully to prevent laceration. This 
softness is due to the large proportion of water which it contains. 
The following analyses show the composition of the brain in three 
periods of life : 

Infant. Youth. Adult. 

Albumen 7.00 10.20 9.40 

Cerebral fats 3.45 5.30 6.10 

Phosphorus 0.80 1.65 1.80 

Osmazome, salts 5 96 '8.59 10.19 

"Water 82.79 74 26 72.51 

At birth the brain has a nearly uniform white color. The gray sub- 
stance, in which the nervous power originates, is undeveloped. The 
date of its appearance corresponds with the first exhibition of emotion 
or intelligence, and the decided gray color which we observe in the 
brain of the adult does not appear until the age of full mental activity. 

In the newborn the brain is large in proportion to the rest of the 
body, and its growth during infancy and childhood is rapid. Until the 
fifth year, as appears from the observations of Dr. Peacock, its weight 
is about one-seventh or one-eighth that of the entire system, the pro- 
portions varying somewhat in different cases. 

The brain does not attain its full size, as stated by Dr. West, at the 
age of seven years, but, according to Dr. Peacock's statistics, it con- 



ACEPHALUS — ANEXCEPHALUS. 415 

tinues to increase till the age of twenty-five or thirty, although its 
growth is less rapid after the age of seven years than previously. 

The membranous covering of the cerebro-spinal axis is scarcely less 
interesting to the pathologist than the axis itself. I shall speak in the 
following pages of the arachnoid and cavity of the arachnoid, for conve- 
nience of description, although aware of the fact that some eminent 
authorities, as Virchow and Kolliker, w r hose opinions in reference to the 
minute anatomy of the system always command attention, if not assent, 
believe that there is no arachnoid, but what has heretofore been called 
by this name is on the one side the smooth surface of the dura mater 
and on the other of the pia mater. 

The dura mater is seldom involved in the diseases of early life, except 
as it is aifected by pressure, while the pia mater and arachnoid are the 
seat and v source of some of the most important diseases, as meningitis, 
meningeal apoplexy, etc. 

The more complicated and delicate the structure of an organ, the 
more liable it is to errors of nutrition and growth. There is, therefore, 
no organ which is so liable to irregular development as the brain. It 
may be entirely wanting; or it may be partially developed, certain 
portions being absent; or, lastly, its growth may be excessive, consti- 
tuting hypertrophy. 



CHAP TEE I. 

ACEPHALUS— ANENCEPHALUS. 

Entire absence of the encephalon is not common, but there are many 
cases of this monstrosity on record. In extreme cases the head and 
part of the neck, as well as the brain and medulla oblongata, are absent. 
When there is great deficiency there is often a twin, the presence of 
which has interfered with the full development of the foetus. Some- 
times the growth of other organs besides the brain is imperfect. 

Anatomical Character. — In the ordinary form of anencephalus 
the brain and sometimes the medulla are absent, with the absence or 
imperfect development of their membranous and osseous covering. The 
vault of the cranium is absent. There is deficiency of the frontal, 
parietal, and occipital bones, except those portions which are near the 
base of the cranium. These portions are very thick and closely united, 
as if there were the usual amount of osseous substance, but instead of 
expanding into the arch, it had collected in an irregular mass at the 
base of the cranium. 

The absence of the brain and the cranial arch gives a remarkable 
appearance. The eyes are prominent, the neck thick and short, while 
the body and limbs are ordinarily well developed. The physiognomy 
has been compared to that of some of the lower animals. 



416 



ACEPHALUS — ANENCEPHALUS. 



The base of the cranium is often occupied by a vascular tumor, not 
large, but of different size in different cases, and continuous below with 
the spinal pia mater. The vascular tumor is the representative of the 
cranial pia mater, and its smooth surface is the analogue of the arach- 
noid. The dura mater and the scalp being absent, the exposed mass 
resembles very much in appearance, as it does in structure, the placenta, 
and the sensation which it imparts to the finger pressed upon it is very 
similar. Sometimes small portions of cerebral matter are found among 

Fig. 27. 




the vessels of this tumor, but they are so disconnected or isolated that 
they do not perform, in any way, the function of a brain. Occasionally 
the vascular tumor is absent and the medulla or upper extremity of the 
spinal cord is exposed, or it terminates in a little papilla at the back of 
the neck. 

Those portions of the cranial nerves which lie external to the cranium 
are well developed, although the intracranial parts may be absent. 

Symptoms. — The respiration in anencephalous monsters is irregular. 
They can be made to cry, but their cry is a sort of sob or hiccough, and 
occasionally they even nurse. The digestive function is well performed, 
and regular urinary and fecal evacuations occur. There is a tendency 
in anencephalous monsters to convulsions. Blowing upon them, and 
pressure upon the projecting medulla, if this be present, frequently pro- 
duce this effect. 

Prognosis. — Fortunately these monsters are short-lived. If the 
medulla oblongata, which is essential to the maintenance of respiration, 
be absent, extrauterine life is impossible. Stillbirth is the result. If 
the medulla oblongata be present, although respiration and circulation 
are established, death commonly takes place within two or three clays, 
and almost always within the first week. Convulsions sooner or later 
occur, ending in fatal coma. 



IMPERFECT BRA IX. -il' 



CHAPTEE II. 

IMPERFECT BRAIN. 

Between the absent and complete brain there are various grades of 
deficiency. Parts of the brain may be perfect, while other portions are 
either absent or imperfectly formed. The deficiency is usually in the 
superior parts of the brain, especially in the hemispheres of the cere- 
brum, while the base of the organ is perfect. Both hemispheres may 
be absent, or one may be absent, while the other hemisphere is shriv- 
elled or rudimentary. Occasionally the cranium preserves its normal 
shape and size, in consequence of an increase in the cerebro- spinal fluid 
proportionate to the lack of brain-substance. The imperfect develop- 
ment is not then apparent to the observer. The rudimentary hemi- 
spheres in these cases are spread out, forming the walls of a sac inclosing 
the liquid. The post-mortem examination of the following case was 
made in the Nursery and Child's Hospital, of this city, in 1862. 

Case. — Female ; parentage healthy ; she was plump and well formed 
at birth, and nothing unusual was observed in her condition, as she 
nursed and throve like other children, till she reached the age when there 
is, usually, the first manifestation of intelligence. With her there was no 
evidence of any intellect, or, if any, it was very indistinct. She nursed, 
or took food when placed in her mouth, but apparently without relish, as 
if instinctively. She never reached her hands toward the nurse, or toward 
playthings. So indifferent and apparently unconscious was she of objects 
around her, that it was thought for some time that she was blind. She 
never smiled, except when her hands were gently rubbed or shaken ; and 
then the smile seemed to be a movement more reflex than emotional. The 
smile was immediately succeeded by a fixed vacant look. She usually lay 
quietly, with her arms crossed ; and during the last month of her life she 
sometimes uttered a scream, like children with cerebral diseases. Her 
evacuations were regular, and she was not subject to vomiting, before she 
was attacked with the acute disease of which she died. The size of her 
head was rather less than usual at her age, but not less than is often seen 
in well-formed children. The forehead was small in proportion to the 
rest of the head, but the difference was not such as to attract attention. 
Fortunately, the existence of this idiot was terminated by an attack of 
entero- colitis at the age of about ten months. 

Sedio Cadav. — The head was measured, but the measurements were 
lost. They did not seem to differ materially front the normal standard. 
The sutures were united, and the fontanelles nearly, if not quite, closed. 
The frontal bone lay a little lower than the plane of the parietal. The 
meninges of the brain presented nearly their normal appearance, but were 
distended with transparent serum. The quantity of fluid was estimated 
at about two-thirds of a pint, and when it was evacuated the floor of the 
lateral ventricles was brought into view. There was an almost entire ab- 
sence of that part of the brain which lies above the floor of the ventricles. 

27 



418 IMPERFECT BRAIN. 

On close inspection, rudimentary cerebral hemispheres were found in a 
thin layer forming a part of the walls of the sac. The whole amount of 
brain-substance above the ventricle did not exceed the size of a small egg. 
The cerebellum, the base of the brain, and cranial nerves presented their 
usual appearance. The entire brain, after being a few days in diluted 
alcohol, weighed six and a quarter ounces. 

In this case, the fluid was only sufficient to compensate for the 
deficiency of the brain. In other, and probably the larger number of 
cases of incomplete brain, the cerebro-spinal fluid is not materially 
increased. There is then but slight elevation of the frontal bone, the 
forehead is low, or retreating, or even almost absent. This is that 
shape of head which is universally regarded as characteristic of idiocy. 

Symptoms. — The symptoms in cases of deficient brain relate to the 
mind. If the cerebral hemispheres are absent, there is no intelligence. 
The individual, as regards mental endowments, does not rise above the 
instincts of the lower animals. If the hemispheres are partially devel- 
oped, there is a degree of intelligence proportionate to the amount of 
cerebral substance present. If the deficiency be confined to one side, 
there is no apparent lack of intelligence or mental capacity, since, the 
brain being a double organ, one side performs the functions of both. 

Prognosis. — The prognosis as regards life, in cases of imperfect 
brain, depends not so much on the amount of deficiency as the exact 
seat of arrested growth. If only the cerebrum be partially, or even 
entirely absent, the infant may live and thrive. But if those portions 
lying at the base of the brain, which control the functions of animal 
life, are lacking, or are imperfectly formed, life is very uncertain, and 
probably short. 

It is evident that no therapeutic treatment can remedy a congenital 
deficiency. The services of the physician are not required. The 
philanthropic and patient teacher may impart a degree of intelligence 
to the idiotic, and the instruction of these unfortunates has of late years 
been successful. 



Microcephalia — Atrophy of Brain. 

An abnormally small brain has usually been attributed to premature 
closure of the sutures and fontanelles by too rapid ossification. But in 
certain cases which I have met there was no evidence of exaggerated 
ossification, and the fault seemed to me to be a deficiency in the growth 
of the brain, while the ossifying process was not exaggerated or was 
even less than normal. A normal development of the cranial bones, 
with but little brain-substance to keep them apart, would necessitate 
early obliteration of sutures and fontanelles. Thus in August, 1878, 
an infant was brought into the Bureau for the Belief of the Outdoor 
Poor, with marked microcephalism. Its age was 19 months, and the 
bone formation was so slow^ that only two teeth had appeared ; the cir- 
cumference of its head was 14 J inches ; it had had repeated convulsions 
since the age of five months, and the mother stated that its head had 



MICROCEPHALUS — ATROPHY OF BRAIX. 419 

been round and hard from its birth. In microcephalia, death, sooner 
or later, is the common result ; life ends in convulsions and coma. 

Again, the brain of the child, when undergoing development, with the 
cranial bones sufficiently yielding, may not only cease to grow, but may 
even diminish in size, in consequence of protracted and exhausting dis- 
seases. Diminution in the size of the brain occurs especially after 
fevers and diarrhoea! affections of long standing and attended with much, 
emaciation. The waste of the brain corresponds with the general loss 
of flesh. If the cranial sutures be not united, the occipital and some- 
times the frontal bones are depressed, according to the diminished size 
of the brain, and are overlaid by the parietal. In foundlings of two or 
three months, this loss of brain-substance is often very striking. In 
infants of this class who have died of protracted diarrhoea, it is not 
unusual to observe the occipital bone not only depressed, but extending 
one, two, or even three lines underneath the parietal. 

If the child with shrunken brain, from protracted and exhausting 
disease, be old enough to express its thoughts, it often seems foolish, 
talks but little, and perhaps says the same thing over and over again. 
In one case in my practice, a little girl, having passed through a long 
course of typhus, persistently repeated during her convalescence, with 
a silly smile, the questions addressed to her. This peculiarity con- 
tinued two or three weeks, although her appetite was good, and her 
restoration to health rapid. In another case a little boy, during con- 
valescence, was wont to laugh heartily at the appearance of the ordinary 
articles of furniture in the room. Both showed more impairment of 
mind during convalescence than in the midst of the fever. The friends 
of such children are in a state of great anxiety lest their minds be per- 
manently enfeebled, but, as the appetite and strength return, the nutri- 
tion of the brain is reestablished, and the mind regains its former vigor. 
In cases of wasted brain, with cranial bones united, the deficiency is 
supplied by serous effusion, which is gradually absorbed as the health 
of the patient is reestablished, and the brain enlarges. This effusion 
occurs not only over the convexity of the brain, but also at its base, and 
sometimes in the ventricles. Dr. West states that in atrophy of the 
brain, from protracted disease, its texture is firmer than usual. I have 
not noticed this in infants, but my attention has not been directed par- 
ticularly to this point. It is probable that there is some change in the 
anatomical character of the brain, aside from mere waste. 

Partial atrophy of the brain sometimes, also, occurs from primary 
disease located in this organ ; the affected portion wastes, while the rest 
retains its normal development. 



420 HYPERTROPHY OF BRAIN. 



CHAPTEE III. 

HYPERTROPHY OF BRAIN. 

In contrast with atrophy of the brain is the opposite state, or hyper- 
trophy. The size of this organ within the limits of health varies greatly 
in different individuals, but sometimes there is so great an increase in 
volume as properly to constitute a disease. Fortunately hypertrophy 
of brain is rare in America. 

Pathological Anatomy. — The excess of growth which characterizes 
this disease has been ascertained to be confined to the white portion of 
the brain, and ordinarily to that part contained in the cerebral hemi- 
spheres. Hypertrophy of the brain is attended by induration, which 
exists in different degrees in different cases. It is in some so slight as 
to be scarcely appreciable ; while in others it is apparent at once by 
pressure with the finger, or incision with the scalpel. Rilliet and 
Barthez state that the induration in some cases resembles in degree and 
appearance that produced by the action of alcohol. The white sub- 
stance of the cerebrum is not only resisting and elastic, but its color is 
unusually pale ; it presents even a brilliant or polished appearance. At 
the same time the gray substance is more or less faded, and its depth in 
the convolutions is less than in the normal state of the organ. Roki- 
tansky sa}^s : " The cineritious matter is generally of a pale grayish-red 
color. The medullary is always dazzling white, and remarkably pale 
and anemic." An unusual case is related by Burnet, in which the 
gray substance in the corpora striata retained its usual color, and was 
indurated like the white substance. In exceptional instances the cere- 
bellum as well as cerebrum undergoes hypertrophy, becoming at the 
same time more or less indurated. In Burnet's case there was indu- 
ration of the optic nerves. " The internal structure," he says, " of the 
optic nerves, especially in their bulbs, had the polish, homogeneous 
appearance, elasticity, and almost the hardness of cartilage." Rilliet 
and Barthez state that in two cases the spinal cord presented even more 
marked induration than the encephalon. Congestion is not a feature 
of hypertrophy. On the other hand, there is often less vascularity of 
the brain and its membranes than in the healthy state. If the cranial 
bones be completely ossified at the time when hypertrophy commences, 
and firmly united, enlargement of the brain is partially prevented. The 
convolutions are then thin, much flattened, the sulci more or less effaced, 
the membranes pale and dry, and the ventricles are small and nearly 
destitute of serum. At the autopsy of such a case, when the dura mater 
is incised, the expansion of the brain prevents the proper refitting of the 
skullcap. Occasionally hypertrophy causes more or less absorption of 
the cranium, and perhaps the sutures already united are pressed apart. 

If hypertrophy commence in young infants with the fontanelles and 



SYMPTOMS. 421 

sutures still open, they usually remain open, or are a long time in uniting. 
The interspaces continue, not only in consequence of the growth of the 
brain, which tends to separate the bones, but also in consequence of 
feeble ossification. The shape of the head arrests attention. Hyper- 
trophy usually produces most enlargement between and above the ears, 
while the frontal portion of the head, though somewhat enlarged, is less 
developed. 

The direction of the eyes is not changed, as is common in congenital 
hydrocephalus. 

Rokitansky says (vol. iii. page 285): "With regard to the question 
to be decided by the theory and microscopic examination, as to the 
nature of the added material upon which the increase of volume de- 
pends, I have formed the following opinion from repeated investigations: 

" 1. The disease is genuine hypertrophy. 

" 2. It consists, as such, not in an increase in the number of nerve- 
tubes in the brain, from new ones being formed, nor in an increase in 
the dimensions of those which already exist, either as thickening of their 
sheaths, or as augmentation of their contents, by either of which the 
nerve- tubes would become more bulky ; but, 

" 3. It is an excessive accumulation of the intervening and connect- 
ing nucleated substance." 

It is now generally admitted that the views of Rokitansky are cor- 
rect; that hypertrophy of the brain is due to an augmentation in the 
amount of connective tissue which lies between and unites the tubules. 

Causes. — Hypertrophy of the brain results from an error in the 
nutritive process which sometimes seems to be associated with the rachitic 
state, or a condition analogous to rachitis. It is not common, is indeed 
rare, in this country, and is more common in countries like England, 
where rachitis is more prevalent than with us. Rilliet and Barthez 
consider frequent congestions of the brain as a common cause. The 
hypertrophy is most frequently met in hospitals for children, and among 
the poor of cities, whose systems are rendered cachectic by residence 
in damp and dark localities, and by unwholesome diet. In the deep 
valleys of Switzerland, and in parts of South America and Asia, hyper- 
trophy of the brain is common, under the name cretinism. It is asso- 
ciated with rachitis and stunted growth. The abnormal development 
which occurs in cretinism begins in infancy or early childhood, and the 
unfortunate subjects of it are short-lived. Cretinism has been attributed 
to a residence in localities wet and deprived in great measure of solar 
light, and to general disregard of the laws of health on the part of those 
affected as well as their parents. 

The observations of different physicians also establish a connection 
between some cases of hypertrophy and the saturation of the system by 
lead. In what way lead-poisoning leads to hypertrophy is obscure, but 
the concurrent testimony of different observers is so strong, that we can- 
not doubt that it does sometimes have that effect. But in a considerable 
proportion of cases, as in the one presently to be related, the cause is 
obscure. 

Symptoms. — The symptoms, as is the case with most organic diseases 
of the brain, vary considerably in different patients. Sometimes there 



422 HYPERTROPHY OF BRAIN. 

is, at first, more or less depression or languor. If the child be old 
enough to speak, he may complain of pain in the abdomen or limbs, 
evidently neuralgic, or of headache. After a variable time vomiting 
succeeds, and finally convulsions, affecting the muscles of the face as 
well as extremities; the convulsions are usually clonic, but sometimes, 
as regards at least the extremities, of a tonic character. The pupils 
may be contracted or dilated; there is restlessness alternating with 
droAvsiness, and finally coma succeeds. 

Hypertrophy may continue a considerable time before serious symp- 
toms arise; but when once developed, these symptoms ordinarily con- 
tinue with more or less severity till death. Death commonly results 
within a week after their commencement, but sometimes not till several 
weeks have elapsed. When death occurs at an early period in the dis- 
ease, there is usually firm ossification and union of the cranial bones, 
and, therefore, but moderate enlargement of the cranium. 

If hypertrophy commence at a period not far removed from birth, the 
bones, of course, yield more readily to the pressure, and acute symptoms 
do not occur so soon. After a time, however, in all or nearly all cases, 
convulsions supervene. These indicate the gravity of the disease, and 
are prognostic of its fatal termination. 

In a patient observed by Burnet, violent convulsions, followed by loss 
of consciousness, marked the commencement of acute symptoms, Five 
days subsequently, the following symptoms were recorded : mobility of 
the eyes, without expression; pupils contracted, and directed upward; 
divergent strabismus of the left eye ; the senses in their normal state, 
with the exception of sight ; the limbs move by volition. For a month 
there was little change. Then occurred drowsiness, and increased pros- 
tration, and five weeks later the child succumbed with the symptoms of 
double pneumonia. 

Such is the clinical history of hypertrophy. In cases of firm ossifica- 
tion of the cranial bones, and, therefore, no marked enlargement of the 
skull, the symptoms are similar to those which occur if the dimensions 
of the head be increased, but compression and death result sooner. 

The following case, in which the sutures were firmly united, I attended 
in 1864. The head was large, but not so large as to attract attention 
from its disproportion: 

Case. — A boy, aged two years and two months, had, when about one 
year old, intermittent fever, and since then his countenance was uniformly 
pallid, and his flesh soft. Weaned at the usual time, he remained well 
till the 1st of January, 1864. In the beginning of this month he was ob- 
served to be feverish for some days, and his appetite poor. His health 
then gradually improved, and he was thought to be entirely well. 

On the 26th of February he was suddenly seized with convulsions, gen- 
eral at first, but most severe and continuing longest on the left side. The 
convulsions lasted a little more than three hours. He recovered fully his 
consciousness by the following day, but his appetite remained poor ; he 
was no longer amused by his playthings, and was very fretful. The sur- 
face was pallid ; bowels constipated ; pulse but little, perhaps not at all, 
accelerated. He continued in this state till the 6th of March, when he 
had another slight convulsive attack, and from this time he never fully 



DIAGNOSIS. 423 

recovered his consciousness. He was fretful if disturbed, his face gener- 
ally pallid, while the pulse and respiration were not perceptibly altered. 

On the following day, the 7th, the left pupil was somewhat larger than 
the right, but both were sensitive to light. The difference in size con- 
tinued till near the close of life. Although vision was imperfect, if not 
altogether lost, the sense of hearing was not impaired. 

When questioned, he uniformly answered, " No," with a drawling voice, 
evidently not understanding what he said. 

As the disease advanced, the respiration became at times sighing ; but 
the rhythm of the pulse was not materially altered. The temperature of 
the surface was changeable, sometimes cool, sometimes warm, and the con- 
gested spots or patches, so common in cerebral affections, were also ob- 
served at times on the face, ears, or forehead. Through most of his sick- 
ness he took drinks readily, and the urine was freely discharged, probably 
from the iodide of potassium, Avhich he took in one and a half grain doses 
every two hours. 

He became more and more drowsy, again had slight convulsive move- 
ments, and finally died, with much apparent suffering, on the 14th of 
March. The pulse became more accelerated during the last two or three 
days. On the day preceding his death, the pupils were contracted, and 
not affected by light. 

Sectio Cadav. — Body somewhat emaciated,' and eyes sunken ; occipito- 
frontal circumference of head nineteen and a half inches ; distance from 
one auditory meatus to the other over the vertex, thirteen and a half 
inches ; convolutions over the surface of the brain much flattened and 
compressed ; brain generally deficient in blood ; medullary substance firm, 
and of a pure white color ; meninges healthy ; no other abnormal appear- 
ances were observed ; weight of brain forty-two ounces. 

Diagnosis. — The diagnosis of hypertrophy is not always easy. The 
symptoms are, in the main, such as occur in other pathological states, 
especially congenital hydrocephalus. There is most danger of mistaking 
the overgrowth for this disease. Hypertrophy has, indeed, often been 
treated for hydrocephalus. There are, however, certain signs by which 
we may distinguish one from the other. In the ordinary form of con- 
genital hydrocephalus, even when the amount of liquid is small, the 
orbital plates of the frontal bones are pressed in such a way that the 
axis of the eyes is changed so as to have a downward direction. The 
white of the eye can be seen between the iris and the upper eyelid. 
This gives a characteristic and striking expression to the face. The 
exception to this is in those rare cases in which the liquid is external 
to the brain. In hypertrophy this peculiar change in the axis of the 
eyes does not occur. Moreover, in hypertrophy there is not that uni- 
form expansion of the head which is observed in hydrocephalus, as has 
been stated above. There are, commonly, greater enlargement, more 
prominence of the anterior fontanelle, and wider separation of the cra- 
nial bones, in hydrocephalus than in hypertrophy. But since in some 
cases of hydrocephalus the sutures are united, and the fontanelles 
closed, and there is no change in the direction of the eyes, the reason 
of the difficulty in making a positive differential diagnosis between 
these two diseases in certain instances is apparent. 

Hypertrophy with consolidation of the cranial bones, and, therefore, 



424: THBOMBOSIS IN THE CRANIAL SINUSES. 

little enlargement of the head, may be mistaken for meningitis. The 
history of the case, and the means by which we diagnosticate the latter 
affection, which will be described in their proper place, will usually 
enable the physician to make a correct diagnosis. 

Prognosis. — In forming an opinion as to the probable termination 
of the disease, we must have regard to the age and general condition of 
the child, as well as to the degree of hypertrophy. If the disease com- 
mence at an early age, when the cranial bones are not firmly united, it 
is probable that there will be no compression of the brain, so as to 
endanger life, for a considerable period. We may then hope by proper 
measures to remove the constitutional state which gives rise to the 
hypertrophy, before the enlargement is such as to cause cerebral symp- 
toms. If the bones have already united when the disease commences, 
even slight hypertrophy will produce symptoms, and a speedily fatal 
result is inevitable. Evidently, also, a child in a marked degree rachitic 
or scrofulous is much less likely to recover than one whose general 
health and constitution are less impaired. 

Treatment. — The treatment in hypertrophy should be directed 
mainly to the constitution. Measures calculated to improve the nutri- 
tive process are those most -likely to check the abnormal growth of the 
brain. As the disease is one of perverted nutrition, and usually coexists 
with a vitiated or impoverished state of the blood, tonic and alterative 
remedies are required. The syrupus ferri iodidi is, therefore, useful, 
as it is both tonic and alterative. This may be given in doses of three 
or four drops to a child one year old, three times daily. Cod-liver oil, 
with or without the iron, is beneficial in some cases. Another remedy 
is iodide of potassium in combination with a tonic, as the compound 
tincture of bark. 

B=. — Potass, iodid. 3;j. 

Tinct. cinchon. comp.,_ 

Syr. limon aa ^ij. — Misce. 

One teaspoonful, three times daily, to a child of three years. 

The hygienic treatment is not less important than the medicinal. 
There is little hope of a favorable issue in any case, unless the regimen 
be such as will conduce to a more robust and healthy state of system. 
The diet should be plain and nutritious, the apartments clean and airy, 
and all undue excitement should be avoided. 



CHAPTEE IY. 

THBOMBOSIS IN THE CBANIAL SINUSES (PHLEBITIS). 

The formation of fibrinous coagula within a vein or sinus is desig- 
nated thrombosis (thrombus, clot). Coagulation of fibrin in the cranial 
sinuses occasionally occurs, constituting a very serious pathological state. 
This may result from local disease in the sinuses or in their vicinity, or 



ANATOMICAL CHARACTERS 425 

from disease external to the cranium. The immediate cause of throm- 
bosis, whatever its location, is sufficient arrest of the circulation to allow 
the fibrin to coagulate. 

Tubercular and enlarged bronchial glands, compressing more or less 
the venae innominata, or the descending vena cava, sometimes give rise 
to thrombosis in the cranial sinuses, the fibrin coagulating in conse- 
quence of retardation in the current of blood. I have known throm- 
bosis, in the same situation, also to result from clonic convulsions, occur- 
ring in connection with severe spasmodic cough in pertussis, since both 
the cough and convulsions retard the flow of blood in the veins and 
sinuses within the cranium. At the post-mortem examination of at least 
four such cases I found whitish clots in the lateral sinuses. 

Thrombosis, in the cranial sinuses, may also occur from inflammation, 
either in the walls of the sinuses or immediately exterior to them. This 
is the disease which writers have designated phlebitis of the cranial 
sinuses, and for a correct understanding of the morbid anatomy of which 
the profession are indebted to Virchow. 

Axatomical Characters. — If a child die with the cranial sinuses 
and the veins of the brain and of the meninges in their normal state. 
the blood in these vessels is found at the autopsy dark but liquid, or 
there are small, dark, and soft clots in the larger sinuses. If there were 
congestion, but no coagulation, in these vessels in the last hours of life, 
the clots are more numerous, larger, and longer, sometimes extending 
from the sinuses into the larger veins which empty into them, but they 
are still dark and soft, readily falling to pieces when handled. If, 
again, there have been that degree of congestion and stasis which has 
resulted in ante-mortem coagulation, or in thrombosis, the clots are, in 
part at least, whitish, and of a fibrinous or gelatinous appearance : they 
were formed while the red corpuscles were still carried along in the 
circulation. 

Most of the clots in thrombosis are free, while others are attached 
lightly to the internal surface of the sinus; occasionally they are so 
large as to distend the vessel. They extend also in many cases into the 
cerebral veins which connect with the sinuses, producing prominence 
and firmness, so as to resemble (Rilliet and Barthez) an artificial injec- 
tion. The clots do not present a uniform character. In parts of a 
sinus they consist of almost pure fibrin, of a yellowish-white color, while 
in other portions they present a gelatinous appearance from the large 
number of white corpuscles, while other portions are more or less tinged 
from the presence of red corpuscles. The central part of the clot, after 
a time, if the case be sufficiently protracted, softens, and presents a puri- 
form appearance. This substance, which is only disintegrated fibrin, 
was supposed to be pus, till the microscope revealed its true character. 
It is obvious that small clots forming within a sinus, and having; no 
attachment to its walls, are liable to be carried by the current of blood 
into the general circulation, unless there be complete obstruction. 
Virchow has also shown how a thrombus may extend, by gradual pro- 
longation, nearer and nearer the heart, so that one commencing in a 
sinus may. after a time, reach into the jugular vein. Different ob- 
servers, as M. Tonnele, and also Rilliet and Barthez, have traced the 



426 THROMBOSIS IN THE CRANIAL SINUSES. 

fibrinous masses as far as the cava. The latter writers relate the case 
of a girl, four and a half years old, in whom the sinuses on the left side, 
especially those nearest the petrous portion of the temporal bone, were 
completely filled with clots of a yellowish-white color, intermixed with 
central dark spots. Similar coagula were also found in the left jugular 
vein as far as the brachio-cephalic trunk. Whether the walls of the 
sinus undergo any change depends on the nature of the disease which 
causes the thrombosis. If it be phlebitis, the coats are thickened from 
infiltration and injected, and the internal coat has lost its polish. If it 
be some obstructive disease in the course of the circulation, or a general 
cause, the coats of the vessel are unaltered, except that they may be 
stained by imbibition of the coloring matter of the blood. In an infant 
who died of this disease in the practice of Dr. West, " the sinuses on the 
left side were healthy, but the blood was almost entirely coagulated. 
The posterior half of the longitudinal sinus, the torcular, the left lateral, 
and the left occipital sinuses, were blocked up with fibrinous coagula, 
precisely such as one sees in inflamed veins, and the clot extended into 
the internal jugular vein. The coats of the longitudinal, and of the inner 
half of the lateral sinus, were much thickened, and their lining mem- 
brane had lost its polish, was uneven, and presented a dirty appearance." 

The mode in which congestion and coagulation occur within a sinus, 
in consequence of the pressure of a tumor upon this vessel, or upon a 
vein into which the blood from this sinus flows, is sufficiently obvious. 
The mode of the production of thrombosis, as a result of clonic convul- 
sions, or of the spasmodic cough of pertussis, is also apparent. How it 
results from inflammation of the walls of a sinus, that is, from phlebitis, 
was not understood till explained by Virchow. 

The fibrinous coagula which fill the sinus are not an exudative pro- 
duct, as was formerly supposed. Inflammation (in most cases otitis, 
with caries of the petrous portion of the temporal bone) approaches a 
sinus. The inflammatory products pressing against the walls of the 
sinus diminish its calibre at that point, and hence the retardation of 
blood and the coagulation. Or the walls of the sinus may be thickened 
by inflammatory infiltration, or even by the formation of little abscesses 
within the coats in consequence of the inflammation, so as to produce 
bulging inward, and the result, as regards the circulation, is the same. 
Whether, therefore, the inflammation occur with'out a sinus, or within 
its walls, thrombosis equally results, provided that the diameter of the 
vessel is sufficiently narrowed by the presence and pressure of inflam- 
matory products. 

There is no exudation on the internal surface of a sinus or vein when 
inflamed, as there is upon serous surfaces. " On the contrary 1 when 
the wall is inflamed, the exuded matter (exsudatmasse) passes into the 
wall, which becomes thicker, cloudy, and subsequently begins to sup- 
purate. Nay, even abscesses may form which cause the wall to bulge 
on both sides like a variolous pustule, without any coagulation of the 
blood ensuing in the cavity of the vessel. At other times, certainly, 
phlebitis, properly so called (and in like manner arteritis and endocar- 

1 Cellular Pathology, translation, p. 236. 



SYMPTOMS. 427 

ditis), is the cause of thrombosis, in consequence of the formation of in- 
equalities, elevations, depressions, and even ulcerations upon the inner 
wall which favor the production of the thrombus. Still, whenever phle- 
bitis, in the usual sense of the word, takes place, the alteration in the 
coat of the vessel is almost always a secondary one, and, indeed, occurs 
at a comparatively late period." 

This view of the pathology of thrombosis comports with facts observed 
at autopsies, and which cannot be explained according to the old theory 
of phlebitis, namely, smoothness of the internal surface of the sinus; 
natural color of this sinus, or simple staining from blood; the non- 
attachment or slight attachment of the coagula, etc. 

Causes. — Some of these have been already stated at the commence- 
ment of this article. It is evident from what has been said that this 
disease may be produced by any cause which obstructs the return circu- 
lation from the head. I have already alluded to tumors which press 
upon the sinus, or on the vein below the sinus, as a cause. Among the 
causes may be mentioned also abdominal tumors, narrowing of the chest 
from rachitis, or caries of the vertebrae, and, finally, compression of the 
jugular vein by a peripharyngeal abscess. 

Sufficient allusion has already been made to inflammation of the in- 
ternal ear as a not infrequent cause. Thrombosis is, indeed, one of the 
dangerous results of chronic otitis. Another cause is a reduced or 
cachectic state of system, apart from any local or obstructive disease. 
It is a noteworthy fact that a large proportion of those affected with 
thrombosis, even when it is immediately due to obstructive disease, are 
cachectic. The explanation of this fact is not difficult. In reduced 
states of the system the action of the heart is feeble, and passive conges- 
tion of the vessels within the cranium is liable to occur. Passive con- 
gestion of the veins and sinuses in protracted diarrhoeal maladies, which 
is described in our remarks upon another disease, is an example in point. 
In this state of feeble circulation very slight obstructive disease may be 
sufficient to cause thrombosis. 

Symptoms. — The symptoms of this disease are often obscure. All 
of them may and do occur in other maladies of the encephalon. In 
cases related by M. Tonnele, cerebral symptoms were well marked, such 
as faintness, dilatation of the pupils, strabismus, grinding of the teeth, 
convulsive movements. There may be an almost total absence of such 
symptoms as w T ould direct attention to the state of the head. This is 
due to the sudden occurrence of death after the clots have formed in the 
sinuses. If the clots are large, death soon results in consequence of con- 
gestion of the brain and meninges, which is proportionate to the amount 
of obstruction. Extravasations of blood and transudation of serum not 
infrequently accompany the congestion and hasten the result. 

Dr. West relates the case of a girl who had a mild attack of scarlet 
fever at the age of eight months, and did not fully recover her health. 
She continued restless and feverish, and had two violent convulsions 
two weeks after the scarlatina. In the folio wino; months she had ana- 
sarca, and when she was nearly a year old another attack of convulsions 
occurred. Fluctuation was now observed in the abdomen, and in a few 
days a sero-purulent fluid began to escape from the umbilicus. When 



■128 THROMBOSIS IN THE CRANIAL SINUSES. 

this discharge had continued eleven days, symptoms of a liquid in the 
right pleural cavity were suddenly developed. She grew weak and 
emaciated, and finally was seized with extreme faintness, with which she 
died in forty-eight hours, at the age of thirteen and a half months. 

At the post-mortem examination a large amount of pus was found in 
the abdominal and right pleural cavities. On the right side of the 
cranium, the sinuses were filled with coagula, and their coats seemed 
healthy. The left lateral and occipital sinuses, the torcular and part of 
the longitudinal sinus, also contained coagula, which extended into the 
jugular vein. The walls of the longitudinal sinus and the internal part 
of the lateral sinus were thickened, and their inner surface had lost its 
polish and was uneven. There was congestion of the brain, with points 
of extravasated blood. If, as is probable, the convulsions were due to 
some other cause, the only symptom which was clearly referable to the 
thrombosis was the sudden faintness. In the four cases of thrombosis 
occurring in pertussis, already alluded to, in which I was enabled to 
ascertain by post-mortem examination the presence and extent of the 
clots, the symptoms, which were apparently due to the thrombosis, were 
those of cerebral congestion. Among these symptoms, stupor, and 
finally coma were prominent. The convulsions which occurred in both 
cases were apparently a cause, and not a result, of the thrombosis. 

Diagnosis. — It is evident, from what has been said, that thrombosis 
of the cranial sinuses can rarely be diagnosticated with certainty. The 
preexistence of otitis will sometimes lead us to suspect its presence, 
especially if the otitis have been accompanied by deep-seated pains. 
Symptoms of cerebral congestion, serous effusion, or apoplexy, occur- 
ring in connection with otitis, protracted convulsions, or glandular or 
other tumors situated so as to compress the vessels which return blood 
from the brain, indicate thrombosis. 

Prognosis. — The prognosis, in any case, is obviously unfavorable. 
The cause is, ordinarily, permanent, or not readily removed, so that 
the clots gradually increase. If the cause be a local obstructive disease, 
death is almost certain, since, in nearly every instance, the obstruction 
is of such a nature that it cannot be removed by medical or surgical 
treatment. It is possible that recovery may take place if the clots are 
few and small, and the cause of the thrombosis be mainly feebleness of 
circulation in consequence of a state of debility. ' We know that clots 
may liquefy, and their elements reenter the circulation ; but such a 
result of thrombosis in a cranial sinus, if it ever occur, is rare. The 
thrombus, by its presence, serves as a point of attachment around which 
more fibrin coagulates, so that the obstruction gradually increases till 
death occurs. 

Treatment. — Thrombosis should be treated by cool applications to 
the head, in order to diminish the congestion, by stimulants and sustain- 
ing measures in case the systolic m ovement of the heart be feeble. Tonics, 
vegetable or ferruginous, are indicated if there be a cachectic state. 



CONGESTION OF THE BRAIN. 429 



CHAPTER Y. 

CONGESTION OF THE BRAIN. 

Congestiox of the brain is not peculiar to infancy and childhood, 
but is much more common in these periods of life than subsequently. 
This is due, in a great measure, to the fact that in the young the circu- 
lation is more readily disturbed by moral as well as physical causes 
than in the adult. 

Congestion of the brain is occasionally primary ; more frequently it 
occurs as a concomitant or sequel of some other affection. Diseases, 
whether constitutional or local, which in the adult have no appreciable 
effect on the vascularity of the brain, often cause in the child a decided 
increase of blood in this organ. 

Causes. — Cerebral congestion is of two kinds, active and passive. 
The former results from a cause which directly affects the brain, and 
increases the flow of blood toward it, or from a cause operating prim- 
arily on the heart, and increasing the frequency and force of its systolic 
movement ; the latter is due to some obstruction in the course of the 
circulation, or to feeble propelling power on the part of the heart. 

Among the causes which most frequently produce active congestion 
of the brain in the child, may be mentioned blows or falls on the head, 
excessive fatigue or excitement, heat, perhaps sometimes dentition, and 
also various inflammatory and febrile affections, especially in their first 
stages. 

Cerebral symptoms occurring in the course of an essential fever are 
no doubt often due, in a great measure, to the irritating effect on the 
brain of the specific principle, whatever it may be, circulating in the 
blood. Occurring in inflammatory diseases which are located elsewhere 
than within the cranium, they are often attributed to functional disturb- 
ance of the brain. The brain, it is said, sympathizes with the affected 
part through the system of nerves which unite them. But observations 
show that symptoms referable to the brain, arising in the commencement 
of the essential fevers and of the phlegmasise, are in many instances pre- 
ceded by, and are therefore, doubtless, in greater or less degree depen- 
dent on, hyperemia of this organ. 

Difficult as it is to ascertain the state of the brain in many diseases 
in which it is involved, we may determine whether or not there be con- 
gestion in the young child by observing the anterior fontanelle. If it 
be elevated and tense in an acute disease, hyperaemia is indicated. Now, 
it is often unusually prominent in fevers and inflammations, especially 
in .their first stages, when cerebral symptoms are present. Its elevation, 
under such circumstances, is obviously coincident with cerebral con- 
gestion. 

The acute inflammations which are most likely to be attended by 



430 CONGESTION OF THE BRAIN. 

cerebral congestion are those of the mucous surfaces and pneumonia. 
Severe coryza, tracheo-bronchitis, entero-colitis, and colitis, commencing 
suddenly with great febrile excitement, are frequently accompanied in 
their initial stage by active congestion of the cerebral vessels. Cases 
like the following, which I find in my note-book, are not infrequent. 
An infant four months old had been sick about tAvo days with coryza 
and bronchitis, when I was called to see it ; the pulse numbered 156 ; 
respiration 64 ; it nursed, and was somewhat restless ; cough frequent 
and dry; bowels moderately relaxed. The mucous membrane of the 
fauces was injected, and coarse mucous rales were present in the chest. 
The anterior fontanelle rose above the level of the cranium, and pul- 
sated forcibly. Soon after convulsions occurred, which were relieved 
by appropriate measures, and on the following day the fontanelle had 
subsided. The patient gradually recovered without any untoward 
symptom. 

Cerebral congestion and convulsions often mark the initial stage of 
active intestinal phlegmasia. This is especially true of dysentery. 
The little patient, perhaps from the very inception of the colitis, is 
drowsy ; its surface hot ; pulse full and rapid. There is sudden and 
momentary starting or twitching of the limbs. The anterior fontanelle, 
if still open, is elevated, and it is not till the lapse of several hours that 
the cause of these symptoms is apparent from the occurrence of bloody 
stools. 

The causes of passive congestion of the brain are very different from 
those of the active form. A common cause is obstruction in a sinus or 
vein by a fibrinous concretion, or by a tumor or abscess external to it. 

I have occasionally met cases in which this form of cerebral conges- 
tion appeared to be plainly referable to obstruction to the return of 
blood from the brain by the pressure of bronchial glands, enlarged by 
hyperplasia in tubercular disease, these bodies diminishing by external 
pressure the calibre of the venae innominate or the descending vena 
cava. Rilliet and Barthez have called attention to such cases in the 
clinical history of tuberculosis. The following case may be cited as an 
example ; it occurred in the infants' service of Charity Hospital, in this 
city, in April, 1866. 

An infant, about one year old, affected with tuberculosis, both bron- 
chial and pulmonary, was observed, during the 'ten days preceding its 
death, to bore the pillow with its head almost constantly, so as to wear 
the hair from the occiput. This movement of the head was the only 
prominent cerebral symptom. Nothing abnormal was noticed in the 
appearance of the eyes, nor was the stomach irritable. A spasmodic 
cough and progressive emaciation attracted attention, but these were 
referable to the tubercular disease. At the autopsy we found the 
cerebral sinuses, veins, and capillaries greatly congested. On tracing 
the veins which return blood from the brain, an inflamed and enlarged 
bronchial gland was discovered in the angle formed by the convergence 
of the right and left vente innominate. This gland, which contained 
but a single point of cheesy degeneration, had attained such a volume 
by proliferation of its cells that it pressed upon both vessels, so that it 



ANATOMICAL CHARACTERS. 431 

had obviously retarded the circulation in each, and given rise to cere- 
bral congestion. 

Passive congestion often occurs in the infant at birth, either from 
tediousness of the labor or delay in the expulsion of the body after the 
birth of the head. If it be simple congestion, and not congestion with 
hemorrhage, it soon passes off. Passive congestion of the brain also 
occurs in severe paroxysms of hooping-cough, in which return of blood 
from this organ is temporarily retarded. All are familiar with the con- 
gestion which occurs in parts external to the cranium, from the severity 
of the cough ; producing epistaxis, extravasations under the conjunc- 
tiva, etc. The extra-cranial obviously indicates the presence and degree 
of cerebral congestion. 

Those who practise in malarious regions sometimes meet cases of dan- 
gerous passive congestion of the brain, the result of malaria, occurring 
especially in the cold state of intermittent fever. In these cases the 
surface is pallid, its temperature reduced, and the pulse feeble. The 
blood, leaving the peripheral vessels, collects in undue quantity in the 
internal organs, producing congestion of the brain, as well as of the 
thoracic and abdominal viscera. In the child with malarial disease, in 
whom there is less vigor of constitution than in the adult, death not 
infrequently occurs in this passive congestion. Two such cases have 
occurred in my practice, although in this latitude the malarial maladies 
are mild in comparison with the type which they present in many parts 
of the United States. 

Symptoms. — The symptoms of. active congestion of the brain are 
stupor, great heat of head, throbbing of carotids, restlessness when 
aroused, twitching of the limbs, and perhaps convulsions. There is 
also sometimes intolerance of light, and the anterior fontanelle, if open, 
pulsates strongly. In passive congestion many of the symptoms are 
the same as in the active form. Stupor, twitching of the limbs, and 
fretfulness or irritability when the patient is disturbed, are common, 
ordinarily without increase of temperature ; the surface may, indeed, 
be cool, and the face is not flushed, nor the eyes injected. The strong 
pulsation and elevation of the anterior fontanelle, so conspicuous in 
active congestion, are — the former always, the latter often — lacking. 
In both forms there is tendency to constipation. 

In many cases the symptoms of congestion of the brain are associated 
with others which proceed directly from the cause of the congestion, 
but it is not difficult, unless in exceptional instances, to determine 
which are due to the congestion, and which to the antecedent and 
coexisting pathological state. 

Anatomical Characters. — In active congestion there is an excess 
of arterial blood in the brain and its membranes. The arteries, to their 
minutest branches, are seen to be full, presenting the bright hue of 
oxygenated blood. In passive congestion the sinuses and veins are 
distended. The pia mater, choroid plexus, and the vessels of the brain, 
have a darker appearance than in active congestion. In both forms of 
congestion, if they continue for a little time, other anatomical changes 
occur. If there be great distention of the capillaries, these vessels are 
liable to give way, and we find here and there little patches of extrava- 



432 CONGESTION OF THE BRAIN. 

sated blood. In other cases the over-distention is relieved by the tran- 
sudation of the serous portion of the blood through the coats of the 
vessels. The cephalo-rachidian fluid is then found in excess external 
to the brain and in the ventricles. 

Prognosis. — The duration and the result of congestion of the brain 
depend, in great measure, on the nature of the cause. If the cause be 
trivial, as mental excitement, fatigue, exposure to heat, there is usually 
prompt relief if the condition of the patient be understood and properly 
treated. If the cause be general or constitutional, as one of the essen- 
tial fevers or hooping-cough, or if it be local, but its seat external to the 
cranium, the prognosis, so far as the congestion is concerned, is not 
unfavorable, if there be a timely and judicious use of remedies. The 
most unfavorable cases are those in which the cause is seated in the 
encephalon, and those in which there is some obstructive disease in the 
course of the circulation. Congestion occurring from a structural 
change within the cranium is, from the nature of the cause, without 
remedy, and ordinarily fatal. Obstructive diseases of the circulatory 
system, wherever located, being for the most part permanent, give rise, 
as a rule, to incurable congestion. 

Congestion of the brain, if it be not relieved in a few hours, becomes 
less and less amenable to treatment. It soon passes beyond the re- 
sources of our art, and ends in coma; it is seldom protracted beyond a few 
days. Extravasations of blood, common in active congestion, and serous 
effusion, common in the passive form, diminish the chances of a favorable 
result. 

Treatment. — The indication for treatment in active congestion is 
plain. Measures should be employed which produce derivation from 
the brain. Unless there be an asthenic primary affection, in the course 
of which the congestion is developed, active purgation is required. A 
saline purgative is ordinarily preferable. If the stomach be irritable, 
there is no better purgative than calomel. In all cases of active con- 
gestion, whatever the cause, the bowels should be kept open. It is often 
better not to wait for the tardy action of a cathartic, but to give at once 
an enema of soap and water or salt and water. External derivative 
agents are also indicated. A warm mustard foot-bath, sinapisms to the 
back of the neck or chest, and to the feet, and cold applications to the 
head, are measures which should never be neglected. In many cases 
those medicines are useful which reduce the contractile power of the 
heart, as aconite. 

This treatment, if employed early, will relieve the congestion in a 
large proportion of cases; but if there be no improvement, if the child 
be robust, and if the primary affection be such as does not contraindicate 
loss of blood, leeches should be applied to the temples or some part of 
the head. If after the lapse of some hours cerebral symptoms continue, 
apoplexy or serous effusion has probably occurred. Congestion is then 
no longer the prominent lesion, and it is proper to designate the disease 
by another name. 

The treatment appropriate for passive congestion is somewhat differ- 
ent; cold applications to the head, and those of a derivative nature to 
the extremities, are useful. As this form of the disease is not primary, 



INTRACRANIAL HEMORRHAGE. 433 

but is dependent on some antecedent pathological state, it is evident that 
it can only be treated successfully by removing or obviating the cause 
so far as possible. But the nature of the various obstructions to the 
intracranial circulation is such that our ability to accomplish this end is 
very limited. 

If the cause be constitutional, or if it be some disease in the neck or 
chest, it may sometimes be partially or even wholly removed, but if 
seated within the cranium it is beyond our control. In general, it may 
be said that depletion is not required or tolerated in passive congestion, 
and stimulants are often needed. 



CHAPTEE VI. 

INTRACRANIAL HEMORRHAGE (MENINGEAL HEMORRHAGE. 
CEREBRAL HEMORRHAGE). 

Hemorrhage within the cranium is not very infrequent in infancy 
and childhood; and there is no part of the encephalon, whether the 
meninges or brain, in which it does not sometimes occur. If the blood 
be extravasated upon the surface of the brain or between the meninges, 
the disease is designated by writers meningeal apoplexy ; if in the sub- 
stance of the brain, cerebral apoplexy. Extravasation may also occur 
in one of the lateral ventricles. This may, for convenience, be described 
as a form of meningeal apoplexy. 

Causes. — Apoplexy is usually (there is an exception) preceded by 
congestion. If the congestion increase to a certain degree, the distended 
capillaries give way and extravasation of blood results. Therefore the 
causes of congestion which have been enumerated in the preceding article 
are, in great measure, those of apoplexy. Recent microscopic examina- 
tions have demonstrated that the corpuscular elements of the blood may 
escape from capillaries without rupture. While, therefore, it is prob- 
able that intracranial hemorrhage in early life commonly occurs from a 
rupture, its occasional occurrence through the walls of the capillaries 
must be admitted. 

Intracranial hemorrhage is not infrequent in the newborn. It results 
in them from tediousness of the birth and severity of the labor-pains. 
At first there is extreme congestion of the meningeal and cerebral ves- 
sels corresponding with that of the scalp and face. This congestion, 
continuing, soon ends in extravasation of blood. In some of these cases 
forceps have been used to effect the delivery, but it is doubtful whether 
the use of instruments materially increases the congestion or the amount 
of extravasation. Certainly, in a large proportion of intracranial as 
well as supracranial hemorrhages of the newborn, instruments have not 
been used. An additional cause of the hemorrhage is, in some instances, 
the use of ergot, which, by producing strong and continuous pains, 

28 



434 INTRACRANIAL HEMORRHAGE. 

interrupts the placental circulation and increases the congestion of the 
foetal veins and capillaries. 

In infants a few days old intracranial hemorrhage may result from 
that rapid and fatal disease, tetanus infantum. The hemorrhage is 
preceded by intense passive congestion, which the tetanic rigidity and 
spasms produce by obstructing respiration and circulation. Few cases 
of tetanus infantum occur without more or less extravasation of blood, 
either meningeal or cerebral. Another cause of this disease is obstruc- 
tion in the vessels which return the blood from the brain. The various 
structural changes which produce this obstruction, in different cases, 
have been sufficiently described in our remarks on cerebral congestion 
and thrombosis. 

The congestion which precedes hemorrhage, when occurring under 
the conditions described above, is passive. 

Among the causes which produce hemorrhage through the inter- 
mediate state of active congestion may be mentioned great mental ex- 
citement, of which M. Legenclre relates a case, and lengthened exposure 
to the sun's rays, an example of which Rilliet and Barthez have seen. 
It is also said that compression of the aorta by an enlarged liver or an 
abdominal tumor has sometimes produced meningeal or cerebral hemor- 
rhage, by causing an increased afflux of blood to the head. A very 
important cause to which I have not alluded, is that general state of the 
circulatory system which is designated by the term purpura hemor- 
rhagica. This sometimes results from the antihygienic conditions in 
which the child is placed. In other instances it results from some an- 
tecedent disease, protracted and debilitating, which has produced a 
profound alteration in the state of the blood and the vessels. The 
capillaries become less firm and elastic, and easily give way, so that in 
such patients ecchymotic points are ordinarily found in different parts 
of the system. The diseases which occasionally end in this hemor- 
rhagic diathesis are numerous. I have known it to occur after measles, 
scarlet fever, and smallpox. It is also an occasional sequel of chronic 
diarrhoea, or intermittent and typhoid fevers, and of rachitis. 

Anatomical Characters. — Hemorrhage in or upon the brain, in 
infancy and childhood, differs in important particulars from that occur- 
ring in adult life. In the adult, and more so as life advances, the 
arteries become less detensible and more brittle, so that when hemor- 
rhage occurs it is usually from one of these vessels. In early life, on 
the other hand, the blood does not ordinarily escape from an artery, 
but, as has been stated, from the capillaries. The extravasation is not, 
therefore, so rapid and violent, and is not attended by such laceration 
and injury of surrounding parts, in infancy and childhood, as at a sub- 
sequent age. In the adult the hemorrhage commonly occurs in the 
substance of the brain. The flow of blood from the ruptured artery 
separates the brain-substance, producing a cavity in which a clot forms. 
This constitutes the usual form of apoplexy in the adult. In the first 
years of life, on the contrary, the extravasation is commonly from the 
meninges, and the symptoms to which the effused fluid gives rise are for 
the most part due to its mechanical effect. Cases of hemorrhage in the 
substance of the brain constitute a small minority, unless during the 



ANATOMICAL CHARACTERS. 435 

days immediately succeeding birth. In early life, therefore, on account 
of its greater frequency, meningeal hemorrhage is a disease of more 
importance than cerebral, and its anatomical character should be care- 
fully studied. 

In meningeal hemorrhage the extravasation may be between the 
cranium and dura mater, upon the visceral layer of the arachnoid, in 
the meshes of the pia mater, or in a lateral ventricle, from rupture of 
the capillaries in the choroid plexus. Much the most common seat is 
external to the pia mater in the so-called cavity of the arachnoid ; the 
blood escaping in this situation spreads uniformly in all directions. It 
soon separates in two portions, the solid and liquid. The solid portion, 
or the clot, is free or but slightly attached to the adjacent membrane. 
The meninges in the vicinity of the extravasated blood preserve their 
normal appearance, or are but slightly injected; the clot gradually 
becomes extended on all sides, so as to form a lamina at the seat of the 
extravasation, thinner at its circumference than centre, and at first of a 
dark red color. The color gradually fades, and the lamina, becoming 
smooth and polished, and at the same time more and more attenuated, 
finally resembles the arachnoid in appearance. Its diameter varies in 
different cases from a few lines to two or three or more inches. M. 
Tonnele relates two observations in which the adventitious membrane 
extended over the superior surface of both hemispheres, and in one of 
them, also, over the falx cerebri. 

The extravasation may occur at any part of the surface of the brain, 
but its usual seat is the vertex. The next most frequent locality is the 
base of the brain. The subsequent history of the delicate membrane 
into which the clot is gradually transformed is interesting. It often 
extends so as to cover more space than was occupied by the extrava- 
sated blood, and its edges are then scarcely distinguishable, in conse- 
quence of their extreme tenuity, and their close resemblance to the 
arachnoid. The attachments of this membrane, so far as it forms any, 
are usually to the parietal surface of the arachnoid. Sometimes a por- 
tion of the membrane is attached, while the rest lies free, bathed on 
either side by the liquid portion of the blood which still remains from 
the extravasation. According to M. Leg;endre, in the most favorable 
cases, the serum is absorbed, and the membrane which has resulted from 
the clot, and which I have described, becomes intimately adherent to 
the internal surface of the dura mater. It forms an integral part of this 
membrane, and there only remain a little thickening and increased 
opacity, indicating the seat of the extravasation. The health is fully 
reestablished. 

But the result in other cases is as follows : The serum is not absorbed, 
and the newly formed membrane, uniting at points with the inner sur- 
face of the dura mater, or its arachnoidal covering, incloses the fluid so 
as to produce a circumscribed hydrocephalus. 

Sometimes there is only one cyst ; in other instances the membrane, 
especially if large, unites in such a way as to give rise to more cysts 
than one. The size of the cyst varies, according to the quantity of fluid, 
which may be only a few drachms or several ounces. Rilliet and 
Barthez report a case in which there was a pint of fluid lying over each 



436 INTRACRANIAL HEMORRHAGE. 

hemisphere, there being two cysts. If the cranial bones arc not united, 
so that they yield to the pressure, the size of the cranium is increased, 
and if the extravasation be confined to one side, an inequality results, 
and the symmetry of the head is destroyed. The fluid which causes 
the enlargement of the head in such cases is in part the serum of the 
extravasated blood, and in part a subsequent secretion. 

Various writers relate cases of ventricular hemorrhage. Valleix met 
it in an infant that died at the age of two days. In the JEdin. Journ. 
of Med. and Surg., October, 1881, an interesting case is related. A 
boy nine years old died of hemorrhage in both ventricles, and also at 
the base of the brain and in the spinal canal. In the Nursery and 
Child's Hospital of this city, the post-mortem examination was made of 
an infant who died at the age of one month. In the posterior cornu of 
the left lateral ventricle were two clots, elongated and black, one larger 
than the other. In the corresponding cornu, on the opposite side, was 
a smaller clot. A similar post-mortem appearance was observed at the 
autopsy of a young infant in the infant service of Charity Hospital. A 
dark crescentic clot lay in each posterior cornu. The clot, if remaining 
a long time, undergoes degeneration. In the case of an adult, in which 
a year had elapsed after the extravasation, I found it to contain crystals 
of cholesterin and carbonate of lime. 

Cerebral Hemorrhage, or hemorrhage in the substance of the 
brain, may occur at any time in infancy and childhood. The blood is 
sometimes extravasated in points, here and there, over the entire organ, 
or a part of the organ; in other cases it is extravasated in one or per- 
haps two cavities, as in the ordinary form of apoplexy in the adult. In 
the first form of cerebral hemorrhage, or that in which the blood escapes 
from numerous points through the brain, there is evidently little lacera- 
tion or injury of the organ. The brain-substance surrounding the 
hemorrhagic points sometimes preserves the usual appearance. It is 
white and firm. In other cases it presents a reddish or yellowish ap-' 
pearance, and is softened to the depth of a line or two. If the hemor- 
rhage occur in a cavity, as in apoplexy of adults, the nerve-fibres are 
evidently torn and separated, and there is more or less compression of 
the surrounding brain-substance. Unless the disease be of long stand- 
ing, the cavity contains a dark and soft clot bathed with serum, which 
has a reddish or a yellowish-red appearance. The brain in the immediate 
vicinity of the cavity is sometimes softened. Rilliet and Earth ez state 
that they have seen eight cases of cerebral hemorrhage of the capillary 
form; ten cases in which the hemorrhage was in cavities; and in two 
of the eighteen both forms were present. In five of those in which the 
form was capillary the disease was limited to portions of the brain, while 
in the remaining three the hemorrhagic points were found in nearly 
every part of the brain. 

Apoplectic cavities are seldom seen in the cerebellum, and, whether 
the hemorrhage be capillary or in a cavity, there is, in most cases, as 
previously stated, more or less congestion of the vessels of the brain. 

The proportion of cases of cerebral to other forms of hemorrhage is 
believed by some to be greater in the newborn than at any other period 
of life. Yalleix relates four cases of intracranial hemorrhage occurring 



SYMPTOMS, 437 

at this age, two of which were cerebral, one ventricular, and in the other 
the extravasation was in the cavity of the arachnoid. Mignot has pub- 
lished eight cases occurring in the newborn, in two of which the hemor- 
rhage was in cavities in the cerebrum ; in three, in the lateral ventricles ; 
and in three, external to the brain. If the same proportion be observed 
in other statistics, one in three of the cases of intracranial hemorrhage 
occurring in the newborn is cerebral. 

Symptoms. — The symptoms in intracranial hemorrhage are not uni- 
form ; they vary according to the seat as well as the quantity of the 
effused blood. In some cases the extravasation occurs without such 
symptoms as would direct attention to the brain. When the hemor- 
rhage occurs at the time of birth, in consequence of strong and long- 
continued labor-pains, the infant is often born apparently dead. This 
is due partly to the hemorrhage, partly to the great congestion of the 
brain which precedes and accompanies the hemorrhage. Resuscitation 
is gradual and difficult. The infant's features are livid, and perhaps 
swollen ; its respiration is gasping, and both pulse and respiration are 
slow. Its cry is feeble, with but slight movement of the facial muscles, 
and the lungs are but partially inflated ; the eyelids are closed, and the 
limbs almost motionless. By artificial respiration and by friction, the 
pulse and breathing may be rendered more frequent, but the latter 
remains irregular and gasping. Finally, the limbs grow cold, the surface, 
from a state of lividity, becomes pallid, and death occurs in profound 
coma. M. Cruveilhier made many observations at the ''Maternity " in 
reference to the death of newborn infants, and he believes that one- 
third of those who die in birth, at the full period, die of apoplexy. I 
have made post-mortem examinations in a few cases, when death had 
occurred from this cause, and in all the hemorrhage was meningeal. 
One of these was born on the 30th of December, 1864. The birth was 
delayed by unusual projection of the promontory of the sacrum, so that 
finally the application of forceps was necessary. The infant was appar- 
ently stillborn, but by persistent efforts on the part of the physician 
who assisted it was resuscitated so as to live several hours, though with 
constant embarrassment of respiration and with lividity. At the autopsy 
a large extravasation of blood was found in the cavity of the arachnoid, 
over a considerable part of the convexity of the brain, and the substance 
of the brain was deeply congested. 

Apoplexy in the newborn does not always terminate fatally, or, when 
fatal, in the sudden manner which I have described. Valleix relates 
the case of an infant who died of pneumonia at the age of three and a 
half months. Its birth had been protracted and difficult, but was com- 
pleted without the use of instruments. It had had during its entire 
life paralysis of the right side. At the autopsy a clot was found near 
the base of the right thalamus opticus, evidently existing from birth. 
Around the clot the brain was softened to the depth of some lines, and 
was of a bluish-red color. A very similar case is related by M. Ver- 
nois. An infant lived forty-nine days with paralysis of the left side, 
and died of pneumonia. At the autopsy a hemorrhagic excavation in 
process of cicatrization was found behind the right corpus striatum and 
the thalamus opticus. 



438 INTRACRANIAL HEMORRHAGE. 

Intracranial hemorrhage occurring from accidents of birth is gener- 
ally attended by marked symptoms, such as have been described. 
But when it occurs subsequently to birth, whether in infancy or child- 
hood, the symptoms vary greatly in different cases, and are generally 
obscure. I will briefly state the symptoms which have been observed 
in both the cerebral and meningeal forms of this disease. First, the 
cerebral. Sedillot relates the case of a child seven and a half years 
old, whose bare head had been exposed several hours to the sun's rajs. 
Suddenly, after a paroxysm of anger, it was seized with great pain, 
corresponding with the posterior and inferior fossne of the cranium. • It 
uttered piercing cries, and died in a quarter of an hour. A clot was 
found in the right lobe of the cerebellum. Richard Quinn (Rilliet and 
Barthez) gives the history of a boy nine years old, who in playing with 
a hoop suddenly stopped, carried his hands to his head, and fell back- 
ward unconscious. Three or four hours afterward when examined, he 
was found pale, surface cool, respiration slow and at times stertorous, 
pulse 50 to 60 per minute ; the left arm was flexed, the left leg para- 
lyzed ; the right leg and arm convulsed ; right pupil strongly dilated, 
the left contracted. He died seven hours after the commencement of 
the attack, and a large clot was found in the centrum ovale on the right 
side. 

Rilliet and Barthez relate the following case from Campbell. A 
boy with good previous health was suddenly seized about 7 A. m. with 
repeated vomiting, and in an hour and a half with violent convulsions ; 
he rolled his eyes and uttered inarticulate cries ; pulse frequent and 
hard ; pupils contracted ; trunk and lower extremities cool. In the 
afternoon he presented symptoms of compression of the brain, such as 
dilatation of the pupils, frequent and feeble pulse. Death occurred in 
the evening, and a hemorrhagic cavity was found occupying the right 
middle lobe of the cerebrum. Guibert relates a case of extravasation in 
the superior part of the right hemisphere of the brain in a boy fourteen 
years old. The principal symptoms were feebleness of the limbs, ina- 
bility to w r alk, cephalalgia, involuntary evacuations, fever, grinding of 
the teeth, rigors severe and prolonged, lividity, loss of intellectual facul- 
ties, dilatation of the pupils, insensibility to light, stertorous respiration. 
Death occurred in about an hour. 

Rilliet and Barthez narrate the history of a girl two years old, who, 
after an attack of measles, was taken with convulsions accompanied 
with fever and prostration. The convulsive movements affected especi- 
ally the eyes and upper extremities ; the right leg w r as immovable ; the 
left pupil dilated. These symptoms resulted from hemorrhage in the 
corpus striatum and opticus thalamus. The same authors relate also 
the case of a girl, seven years old, w T ho died with a large apoplectic 
cavity in the left thalamus opticus. The symptoms were headache, 
convulsive movements, loss of consciousness, delirium, vomiting and 
constipation, and convergent strabismus. These symptoms nearly dis- 
appeared, but in a few days the headache returned, with strabismus and 
a slight drawing of the face toward the left ; on the twenty-seventh day 
convulsive movements of the right eye were observed, with paralysis of 
the arm. Finally contraction of the arms occurred, with acceleration 



SYMPTOMS. 439 

of pulse, irregular breathing, dilated pupils, paralysis, and retraction 
of the head, followed by death on the forty-eighth day. 

These cases, and those from Valleix and Vernois, which have been 
related in our remarks on hemorrhage of the newborn, are sufficient to 
show the character of the symptoms in that form of cerebral hemor- 
rhage in which the extravasated blood forms a cavity in the interior of 
the brain. 

If the amount of extravasation be large, and the substance of the 
brain be much lacerated and compressed, death may occur almost imme- 
diately, and, therefore, without symptoms, or before it is possible to 
determine whether or not symptoms are present. If the disease be not 
so speedily fatal, the symptoms, as appears from the above cases, are 
headache, confusion of thought, or even insensibility, cries, sometimes 
piercing, cold extremities, pallor, slow and perhaps stertorous respira- 
tion, convulsive movements followed by paralysis, or convulsions affect- 
ing one or more limbs, with paralysis of others, pupils contracted or 
dilated, sometimes one contracted and the other dilated, strabismus, 
rolling of eyes, vomiting. 

These symptoms have all been observed in different cases, but they 
are not all present in any one case. Those which are generally present, 
and on which we mainly rely for diagnosis, are headache, convulsive 
movements, paralysis, confusion of thought, irregularity in the pupils, 
and strabismus. 

In the capillary form of cerebral hemorrhage there is usually some 
complication, so that it is not easy to determine how far symptoms are 
due to the hemorrhage, and how far to the coexisting pathological state. 

There are, indeed, but few published observations of cerebral hemor- 
rhage in the substance of the brain unaccompanied with meningeal hemor- 
rhage, hemorrhage into a ventricle, or some other distinct disease, but 
so far as I have been able to ascertain the symptoms referable to this 
form of extravasation, they are as follows : The child is drowsy ; fretful 
when disturbed; it perhaps moans. There are sometimes slight con- 
vulsive movements and partial paralysis. If there be considerable ex- 
travasation, the respiration is irregular and sighing. Death occurs in 
coma, occasionally preceded by convulsions. Taupin relates the case of 
a child nine years old, who died with this form of hemorrhage, accom- 
panied by softening of the brain. The disease began at night, with 
delirium, agitation, and piercing cries. In the morning the patient lay 
in bed, drowsy, not complaining of pain, and not replying to questions; 
pupils dilated, and insensible to light ; left eye half open during sleep, 
and its axis changed; eyebrows contracted; face pale; mouth open; 
had no convulsions, but transient stiffening of the limbs, during which 
the thumbs were firmly compressed by the fingers ; senses unimpaired, 
but the face drawn to the right; deglutition difficult; pulse small, ir- 
regular, and feeble; respiration 32, sighing. In the evening he had 
rigidity of the limbs and back, and, finally, was taken with general con- 
vulsions, in which he died at eleven o'clock. The hemorrhagic points 
in this case were numerous. A boy five years old, whose case is de- 
scribed by Rilliet and Barthez, died of this disease, pneumonia, and 
white softening of the intestine. During the last five days there were 



440 INTRACRANIAL HEMORRHAGE. 

cerebral symptoms, the chief of which were drowsiness, fretfulness when 
disturbed, and moaning without apparent cause. Another child, whose 
case is described by Rilliet and Barthez, died at the age of four years, 
with cerebral capillary hemorrhage, accompanied by yellow softening. 
Six months before death he had general convulsions, followed by spas- 
modic movements of the left side. These subsided, but the left side 
remained feeble. 

In Meningeal Hemorrhage there are often convulsions, general or 
partial, in some patients tonic, in others clonic. When partial, the 
convulsive movements may only occur in the muscles of the face and 
eyes. With the spasmodic muscular action is a degree of drowsiness 
and irritability. Paralysis, so common in the apoplexy of the adult, and 
not infrequent, as we have seen, in the cerebral form of early life, is 
sometimes, but not ordinarily, present in meningeal hemorrhage. In- 
stead of paralysis, there are vomiting, some febrile action, thirst, and 
loss of appetite. The symptoms are different, however, according to 
the exact seat of the hemorrhagic extravasation, and the duration of the 
disease. If the extravasation end in the formation of a cyst, the symp- 
toms are those of hydrocephalus. The following condensed history of 
cases which I have selected as typical, will give us a clearer idea of the 
history and course of the various forms of meningeal hemorrhage than 
can be imparted by a narration of symptoms: 

M. Tonnele relates the case of a child who was taken with faintness 
and convulsive movements. On the following day the trunk and inferior 
extremities became rigid; deglutition was painful; the pupils were 
largely dilated, immovable; face pale; pulse feeble and intermittent. 
Death occurred the same day. The dura mater was distended. A 
layer of coagulated blood, of great thickness, extended over the con- 
vexity of each hemisphere. The veins ramifying in the superior portion 
of the cerebrum were distended with coagulated blood. The hemorrhage 
was in the meshes of the pia mater. Drs. Lombard and Panchard, of 
Geneva, relate a somewhat similar case. A child, thirteen months old, 
was convalescing from inflammation of the bronchial and intestinal 
mucous surfaces, when it was seized with general convulsions ; the mouth 
and eyes were open, and the eyes directed upward; pupils contracted; 
pulse frequent and irregular. The convulsions abated somewhat ; but 
soon reappeared with violence. The patient became insensible, and 
died nineteen hours after the commencement of cerebral symptoms. 
The extravasated blood covered the upper surface of both hemispheres. 
From the above cases we see the symptoms and the course of meningeal 
hemorrhage, when the extravasation is so large that death speedily 
results. In protracted cases of meningeal hemorrhage, there is either a 
gradual disappearance of symptoms and return to health, or, circum- 
scribed hydrocephalus occurring, the symptoms of that disease arise. 

Diagnosis. — It is evident, from what has been stated, that the diag- 
nosis of intracranial hemorrhage is attended with unusual difficulty, since 
the symptoms of this disease occur also in other and distinct pathological 
states. The history of the case, and especially the character of the 
cause, if ascertained, will aid in diagnosis. If there have been an obvi- 
ous determination of blood to the brain, or some known obstruction to 



TREATMENT. 441 

the return of blood from that organ, the persistence of cerebral symp- 
toms would justify us in concluding that either serous or sanguineous 
effusion had supervened on a state of congestion. The points of differ- 
ential diagnosis between apoplexy and meningitis are the sudden and 
full development of symptoms in one case, the gradual commencement 
and gradual increase of symptoms in the other; differences also of symp- 
toms in certain respects; for example, as regards febrile reaction, con- 
stipation, etc. 

There is one symptom in cerebral hemorrhage which is of great diag- 
nostic value, namely, paralysis. Its presence affords strong evidence 
that there is extravasation of blood, and probably in a cavity in the sub- 
stance of the brain. If the extravasation end in the formation of a cyst, 
the symptoms and appearance of hydrocephalus, which, after a time, 
arise, throw light on the nature of the disease. 

Prognosis. — There can be no doubt that many cases of intracranial 
hemorrhage occur and terminate favorably without the nature of the 
disease being suspected. In such cases the amount of extravasated 
blood is small or moderate. In several published cases in which the 
accuracy of the diagnosis was shown by post-mortem examinations, the 
patients were convalescing from the hemorrhage when they succumbed 
to intercurrent diseases. If, however, the amount of extravasated blood 
be such as to give rise to those symptoms which have been described, 
the prognosis is unfavorable. Recurring convulsions, and persistent 
stupor from which it is difficult to arouse the patient, are unfavorable 
symptoms. If the convulsions cease, and consciousness return, even if 
there be paralysis, the result may be favorable. 

Treatment. — The proper treatment in intracranial hemorrhage de- 
pends on the state of the patient, the time which has elapsed since the 
extravasation, and the degree of it, as shown by the nature and severity 
of the symptoms. If, as is often the case, the patient be robust, and be 
visited soon after the commencement of the attack, cold applications 
should be made to the head, mustard to the back of the neck and per- 
haps chest, and derivation should be produced by mustard pediluvia. 
In many cases, especially in active congestion, it is advisable to apply 
leeches to the temple, and the bowels should be opened by a stimulating 
enema. In active congestion, also, prompt purgation by salines or other 
cathartics is sometimes of great importance. The object of such treat- 
ment is to relieve congestion of the cerebral and meningeal vessels, and 
thereby prevent further extravasation of blood. If the congestion be 
active, the pulse continue full and frequent, and the face be flushed, it 
is proper in many cases to control the action of the heart by a seda- 
tive. For this purpose the tincture of aconite root may be given in 
doses of one drop to a child five years old, repeated in three hours if 
necessary, or veratrum viride may be used. If the stupor or convul- 
sions continue after sufficient time have elapsed for the patient to receive 
the full benefit of the above remedies, more active counter-irritation is 
required. Cantharidal collodion should be applied behind each ear. If 
the hemorrhage occur from passive congestion, or in a cathectic state of 
system, active depressing remedies should not be employed. External 
derivatives are of service, as well as cool applications to the head, and 



442 CONGENITAL HYDROCEPHALUS. 

we should attempt, so far as possible, to remove the cause of the con- 
gestion and hemorrhage. If it depend on a cachectic state, tonic or 
other remedies calculated to relieve this state are indicated. The hemor- 
rhage from such a cause is usually in points in the substance of the 
brain, or in moderate quantity over the surface of this organ, and by a 
timely use of constitutional remedies possibly we may prevent further 
extravasation of blood and increase the chance of the patient's recovery. 
If a cyst result from the hemorrhagic effusion, the treatment which is 
proper is that described in the chapter on Acquired Hydrocephalus. 



CHAPTEK VII. 

CONGENITAL HYDKOCEPHALTJS. 

Congenital hydrocephalus consists in an excess of the cerebro-spinal 
fluid, lying either external to the brain, or more frequently in its in- 
terior. It is due to some vice in the development of the brain or its 
membranes, or to a pathological state occurring in them during intra- 
uterine life. This disease is ordinarily apparent from the symptoms and 
appearances at birth, but not always. Occasionally nothing unusual is 
observed in the shape of the head or aspect of the infant till after the 
lapse of some weeks, when the characteristic physiognomy begins to 
appear. In these cases the disease is still congenital, since there is 
every reason to believe that the abnormal state to which the excessive 
production of fluid is clue existed from birth. In cases of arrested or 
partial development of the brain, as, for example, when a considerable 
portion of the hemispheres is absent, there is often an unusually large 
quantity of fluid which serves as a compensation for the lack of brain. 
I do not regard such cases as examples of hydrocephalic disease, since 
the effect of the fluid is not injurious, but rather useful. I restrict the 
term congenital hydrocephalus to those cases in which the brain is com- 
plete, or, if incomplete, the quantity of fluid is more than sufficient to 
supply the deficiency. 

Anatomical Characters. — According to M. Breschet,. the fluid in 
congenital hydrocephalus may be — 1st, between the dura mater and the 
cranium ; 2d, between the dura mater and the parietal arachnoid ; 3d, 
in the cavity of the arachnoid ; 4th, in the ventricles ; 5th, between the 
arachnoid and the brain. 

In a large majority of hydrocephalic patients the effusion occurs in 
the ventricles. As the quantity of fluid increases, the pressure from 
within gradually unfolds the convolutions of the brain, at the same time 
producing expansion of the cranial arch. When the amount of fluid is 
considerable, and it becomes so in the course of a few weeks or months, 



ANATOMICAL CHARACTERS. 



44:3 



the hemispheres are spread out in a thin lamina on either side, gradually 
decreasing in thickness from the base of the cranium to the vertex, 
where the brain-substance is sometimes so thin as to be scarcely per- 
ceptible. Complete absence of brain in this situation, namely, at the 
vertex, even in extreme cases of expansion and flattening of the hemi- 
spheres from the pressure of the liquid, is rare, though the brain-sub- 
stance at this point is sometimes almost as thin as either of the mem- 
branes, so that the wall of the sac is translucent. The membranes which 
surround the brain do not usually undergo any alteration, except such 
as arises from the distention. The falx cerebri sometimes disappears, 
and sometimes the meninges present a whiter hue from maceration than 
in health. The distention also causes such an expansion of the pia 
mater that it becomes very thin, and in places scarcely visible, but its 
presence in every point can be demonstrated. 

The accompanying woodcut represents congenital hydrocephalus as it 
ordinarily occurs. I saw this infant when it was a few days, old, and 
examined it from time to time till its death. The parents are healthy 
and have other healthy children. This infant when nine days old began 

"Fig. 28. 




to have clonic convulsions of a mild form in the muscles of the face, 
neck, and limbs, which occurred almost daily till the age of six weeks, 
and sometimes every five or ten minutes. When the convulsions 
ceased in the sixth week, the head was observed to enlarge, and its 
excessive growth continued till death, which occurred at the age of 
seven months and one week. While the volume of the head progres- 
sively increased, the trunk and limbs emaciated. At death the 
occipitofrontal circumference of the head was nineteen and a half 
inches; the vertical from auditory meatus to meatus thirteen and a 
half inches. 

The changes which the cranial bones undergo, both in their chemical 



444 CONGENITAL HYDROCEPHALUS. 

character and in their shape, in hydrocephalic patients, if the amount 
of fluid be considerable, are interesting and remarkable. The base of 
the cranium undergoes little change, but those portions of the frontal, 
parietal, and occipital bones which constitute the arch are expanded in 
all directions, while they become much thinner. There is deficiency of 
lime in their constitution, so that the organic elements are greatly in 
excess. This renders them flexible and semi-transparent. Notwith- 
standing the expansion of the bones, there are usually interspaces 
between them, of greater or less size, according to the amount of fluid. 

The scalp, being stretched by the pressure underneath, becomes 
tense and thin, and is scantily covered with hair. The veins which 
ramify in it are unusually prominent and large, and the head is elastic 
on pressure, from the amount of liquid beneath. In the common form 
of congenital hydrocephalus, namely, that in which the liquid is in the 
interior of the brain, the shape of the orbital plates of the frontal bone 
is often changed, so that the eyeballs have a downward direction. This 
change in the axis of the eyes occurs at an early period, and it continues 
through the entire disease, becoming more and more marked as the 
quantity of liquid increases. If the amount be large, the lower part of 
the cornea is buried under the under eyelid, while the conjunctiva is 
visible between the cornea and the upper eyelid. The persistent down- 
ward direction of the eyes is characteristic of this disease, and, in con- 
nection with enlargement of the head, is an important diagnostic sign. 
Nevertheless, hydrocephalus even of the ventricular variety, sometimes 
occurs without change in the direction of the eyes. 

If we examine the interior of the cavity after the fluid is evacuated, 
we will find at its base the parts which lie in the floor of the lateral 
ventricles, but changed in appearance in consequence of pressure. The 
cornua are enlarged, and the thalami optici and corpora striata are flat- 
tened. In the early stages of the disease, when the amount of fluid is 
small, there is probably no absorption or destruction of parts in the 
interior of the brain. The various portions of this organ retain nearly 
their normal relation to each other. As the quantity of fluid increases, 
the foramen of Monro, which unites the lateral ventricles, becomes 
enlarged, the septum lucidum which separates them disappears, and the 
two ventricles form a common cavity. In most fatal cases we find this 
single large cavity. The surface which surrounds the cavity occasion- 
ally presents a whitish or semi-opaque appearance, which has led to the 
belief, that at a period antecedent to birth there was subacute inflam- 
mation of this surface, and hence the effusion. 

The bones of the face are ordinarily less developed than in healthy 
children of the same age, so that the disproportion between the head 
and face becomes a marked peculiarity. The shape of the forehead 
and face is nearly triangular. 

The foregoing remarks in reference to the anatomical characters of 
congenital hydrocephalus refer in the main to cases which have con- 
tinued for a considerable time, so that their characteristic features are 
well marked. In very young infants, in whom the disease is still recent, 
similar anatomical characters are present, but in less degree. 

Congenital hydrocephalus is often associated with other vices of con- 



ETIOLOGY. 



445 



Fm. 29. 



formation, especially "with spina bifida. The two, when coexisting, are 
only parts of the same disease; the large quantity of cerebro-spinai 
fluid preventing the spinal canal from closing during foetal develop- 
ment. 

The fluid in congenital hydrocephalus consists largely of water, in the 
proportion even of 99 parts in 100. In addition to this element, there 
are traces of albumen, chloride of sodium, phosphate and carbonate of 
sodium, and osmazome. 

I have had an opportunity to witness only one post-mortem examina- 
tion in a case of congenital hydrocephalus in which the liquid was ex- 
terior to the brain. This case was under observation in the children's 
service of Charity Hospital, in 1866. Full notes and measurements of 
the head were taken, which, unfortunately, were mislaid or lost. The 
infant had congenital syphilis, and had a 
pallid, strumous appearance. The shape and 
relative sise of the head are seen in the ac- 
companying figure, from a photograph. While 
the whole head was enlarged, there was a 
relative excess of development in the part 
between and above the ears. The axis of the 
eyes was not at all changed, and the vision 
was good. The appearance corresponded so 
closely with descriptions of hypertrophy of 
the brain that this was supposed to be the 
anatomical state. Antisyphilitic treatment 
was employed, and the syphilitic eruptions had 
nearly disappeared, when diarrhoea super- 
vened, followed by death. At the autopsy a 

quantity of transparent or light straw-colored liquid, estimated at six or 
seven ounces, was found exterior to the brain, in the great cavity of the 
arachnoid, lying mostly over the superior surface of the organ. There 
was no excess of liquid in the ventricles, and the brain, though of good 
size, was not abnormally large, nor did it possess the firmness which is 
present in true hypertrophy. 

All cases of congenital hydrocephalus may be embraced in two groups, 
namely, that in which the liquid is in the interior of the brain, and that 
in which it lies exterior to the organ. Liquid primarily in the arach- 
noidean cavity permeates the meshes of the pia mater, and lies in part 
underneath it, or this delicate membrane may be ruptured. Four of 
the groups, therefore, described by Breschet, may properly be reduced 
to one, namely, those groups in which the liquid lies under, between, or 
external to the meninges. It is probable that some of the cases which 
led to Breschet's classification were examples of acquired circumscribed 
hydrocephalus, the result of extravasation of blood. In this form of 
hydrocephalus, as is stated elsewhere, an adventitious membrane forms 
external to the liquid, becoming in time thin and delicate, and often 
bearing a close resemblance to the normal membrane (especially the 
arachnoid), for which it is sometimes mistaken. 

Etiology. — The constitutional vice which gives rise to this disease 
is probably different in different cases. I have been able, I think, to 




446 CONGENITAL HYDROCEPHALUS. 

attribute correctly a considerable proportion of cases which I have ob- 
served, to congenital syphilis, but in other instances, from the character 
of the parents I could not assign this cause. 

Symptoms. — Tf there be a considerable amount of hydrocephalic fluid 
prior to the birth of the child, so that the head is abnormally large, par- 
turition is seriously interfered with. The scalp and meninges may 
become ruptured by the severity of the pains, so that the fluid escapes. 
If this do not occur, the labor is often necessarily instrumental. 
Whether the liquid be present before birth or accumulate subsequently 
to it, the tendency is to an increase of the quantity, and a correspond- 
ing enlargement of the head. 

The digestive function in this disease is at first well performed. The 
infant nurses readily, and has its evacuations with the regularity of 
other children. Not many weeks, however, elapse, in the majority of 
cases, before defective nutrition is apparent. 

While the volume of the head increases, other parts are imperfectly 
nourished and stunted in their growth. Emaciation of the neck, trunk, 
and limbs is common, associated with progressive feebleness. In the 
last stages of this disease there is more or less vomiting, with constipa- 
tion. If there were previously the ability to support the head, it is now 
lost and the erect position is no longer possible. In marked cases, 
when there is great disproportion between the head and the rest of the 
system, there is frequently not even the ability to rotate the head on the 
pillow. So long as the cranial bones yield readily to the pressure from 
within, and there is no compression of the brain, the function of this 
organ is not seriously impaired. The child recognizes its mother or 
nurse, and it can be amused like other children, though easily fatigued. 
The state of the senses is different in different cases, and sometimes at 
different stages of the same case. The sight and hearing in some are 
perfect, in others impaired; wdiile in others still they are good at first, 
but gradually become obscured and lost. It is said that the sense of 
smell may be perverted, so that agreeable odors are unpleasant, and 
vice versa. Many, reaching the age at which children begin to walk, 
cannot walk, or, if they do, it is with a tottering, unsteady gait. 

When the liquid increases to that extent, and it usually does sooner 
or later, that the brain begins to be compressed, dangerous cerebral 
symptoms arise. The child becomes drowsy, and takes less notice of 
objects. Spasmodic muscular contractions and finally convulsions occur. 
The pupils act feebly or irregularly by light, or one is more dilated than 
the other. Strabismus also occurs. As death approaches, eclampsia, 
partial or general, becomes more frequent, and is succeeded by stupor 
from which the patient cannot be aroused. 

The following case, which I copy from my note-book, is an example 
of the common form of congenital hydrocephalus. It will give an idea 
of the ordinary course of this disease, and show the difficulty which we 
meet with in its treatment. Female, born November 9, 1859, with the 
aid of forceps. At birth the fontanelles were unusually large, the 
cranial bones separated, and the aspect in a marked degree hydro- 
cephalic. She nursed at first, but, the mother's milk failing, she was 
afterward bottle-fed. At the age of four months her head, which had 



DIAGNOSIS. 447 

increased faster than her general growth, measured from one auditory 
meatus to the other, over the vertex, seventeen inches ; the occipito- 
frontal circumference, twenty-three inches. At this time she mani- 
fested considerable intelligence, being able to distinguish her mother 
from other persons, though the head was so large that it was necessary 
to support it constantly on a pillow. From the age of four to six 
months the operation of tapping was performed six times with a small 
hydrocele trocar, by Prof. Stephen Smith, at a point near the coronal 
suture, and from one inch to one inch and a half from the sagittal. At 
each operation an amount of fluid varying from twelve ounces to one 
pint was removed, and the head then covered with strips of adhesive 
plaster, so as to form a complete cap. It was necessary, however, 
within the twelve hours succeeding each operation, to loosen the dress- 
ing on account of either the occurrence of convulsions or symptoms 
premonitory of them. The head, within a week subsequently to each 
operation, regained its former size, and, as there was no permanent 
benefit, this treatment was discontinued. She finally died of entero- 
colitis at the age of ten months and five days. 

At the autopsy the distance from one auditory meatus to the other 
was twenty and a quarter inches ; the occipitofrontal circumference, 
twenty-six and a quarter inches. The anterior fontanelle measured 
antero-posteriorly four and three-fourths inches ; transversely, seven 
and three-fourths inches. The parietal bones were separated from each 
other to the distance of two or three inches, and they measured in 
length nine and one-half inches. 

On opening the cranial cavity, seven pints, by measurement, of 
transparent fluid escaped, exposing a vast open space, at the bottom of 
which were the parts which constitute the floor of the ventricles, some- 
what changed in shape, and from them, on either side, the hemisphere 
was spread in a lamina, so as to cover the internal surface of the cranial 
bones. The laminae near the base of the brain measured in thickness 
from half an inch to one inch, and they gradually became thinner on 
approaching the vertex, at which point the brain-substance was exceed- 
ingly thin, so as to be scarcely demonstrable. 

The brain had its normal vascularity and consistence, and the cere- 
bellum, medulla oblongata, the base of the brain, and cranial nerves 
presented their usual appearance. On folding the brain together, it 
had the size, shape, and aspect of this organ in its ordinary development. 
Nothing unusual was observed in the membranes except their great ex- 
pansion. The above case corresponds in its general features with most 
cases met in practice. 

Diagnosis. — The ordinary form of congenital hydrocephalus, that 
in which the liquid occupies the interior of the brain, can, in most 
cases, be readily diagnosticated. If there be only a moderate amount 
of liquid, it may be confounded with hypertrophy of the brain. In 
hydrocephalus there are commonly more rapid growth and greater expan- 
sion of the head ; moreover, the enlargement occurs equally on all sides, 
while in hypertrophy, though all parts of the cranial vaults are ex- 
panded, the enlargement is more at the vertex than elsewhere. The 
hydrocephalic head yields more readily to pressure than the hypertro- 



448 CONGENITAL HYDROCEPHALUS. 

phied, and often communicates a fluctuating sensation, Moreover, in 
the ordinary form of hydrocephalus, the change in the axis of the eyes 
described above is an important diagnostic sign. In rachitis the volume 
of the head is often considerably enlarged, due sometimes, in part at 
least, to a deposit of calcareous matter on the exterior of the cranial 
bones. The differential diagnosis is based on the shape of the head, 
round in one, square or with prominences in the other, on palpation, 
direction of the eyes, etc. The smaller the amount of liquid, the greater 
the liability to error of diagnosis ; but if the amount be inconsiderable 
and not increasing, little treatment is required, except hygienic and 
tonic, which is also proper in both hypertrophy and rachitis. If the 
liquid be exterior to the brain, as in the case represented on page 445, 
diagnosis may be difficult, but such cases are infrequent. 

Prognosis. — In the majority of cases this is unfavorable, since the 
secretion of liquid usually continues. The most favorable result is no 
increase, or but slight, in the quantity, while the natural growth of the 
infant increases, and thus the disproportion between the head and the 
rest of the system gradually disappears. Such patients may live to 
maturity, and have tolerable health, and they may engage in occupa- 
tions. But ordinarily in cases left to themselves, and even in a large 
proportion of those having the best treatment, while the quantity of 
fluid increases, the nutrition of the body and limbs becomes more and 
more deficient, and the patient, if not cut off by an intercurrent disease, 
finally succumbs with cerebral symptoms produced by pressure of the 
liquid. Probably more than half of the hydrocephalic patients die be- 
fore the close of the second year. t 

Treatment. — We may attempt to diminish the quantity of fluid by 
the use of diuretics. Digitalis, squills, nitrate and acetate of potassium, 
have been used. The most efficient diuretic in these cases, however, is the 
iodide of potassium. This may be given in doses of one to two grains 
every two hours to an infant of three months. Constipation, if present, 
should be relieved by an occasional purgative. If it be tolerated, we may 
partially prevent the expansion of the head by a close-fitting cap. For 
this purpose strips of adhesive plaster about one-third of an inch in 
width, should be applied so as to cover the entire head. The proper 
way of applying these is as follows : First, one ,strip from each mastoid 
process to the outer part of the orbit on the opposite side ; secondly, 
from the back of the neck, along the longitudinal sinus, to the root of 
the nose ; thirdly, over the whole head, so that the different strips will 
cross each other at the vertex ; and, lastly, a strip long enough to 
pass three times around the head should be applied, passing above the 
eyebrows, the ears, and below the occipital protuberance. Too tight 
an application should be avoided, as it may give rise to convulsions or 
other cerebral symptoms. If the cap can be tolerated, and the general 
health be good, the prospect is more favorable ; but usually, froru the 
increase in the quantity of fluid, it is necessary in a few days to remove 
or loosen the strips in order to prevent convulsions, or, which is prefer- 
able, to diminish the size of the head and relieve the pressure by tapping. 
In 56 cases collected by Dr. West in which tapping was employed, four 
recovered. The operation is simple, easily performed, devoid of danger, 



ACQUIRED HYDROCEPHALUS. 449 

and it frequently gives temporary relief. It should therefore be recom- 
mended to the parents, even if it do not effect a cure. It should be 
performed by a very small trocar, which should be introduced in the 
coronal suture, about an inch external to the anterior fontanelle. A 
few ounces should be removed, and strips of adhesive plaster or an 
elastic skull cap applied. In a few days the operation should be re- 
peated as the liquid increases. It is important to maintain compression 
of the skull before and after the operation (Treves). Sometimes a 
dozen or more tappings are required at intervals of a few days or weeks, 
when the secretion may come to a standstill. In the Med. Ohir. Trans., 
1864, a case is related in which two tappings effected a cure, but so 
good a result is exceptional. Iodine injections in connection with tap- 
ping have so far not produced any satisfactory result. Sir James 
Paget 1 relates a case in which he injected ten grains of iodine and 
twenty grains of iodide of potassium in one ounce of water, but the 
child died of convulsions after the second injection. No appreciable 
good result has followed the use of irritating or sorbefacient applica- 
tions to the head. Nutritious diet and attention to the general health 
are requisite. 



CHAPTEE VIII. 

ACQUIEED HYDKOCEPHALUS. 

Hydrocephalus, or dropsy of the brain, may also occur in those 
who at birth are well formed and free from disease. Pathologists call 
this acquired hydrocephalus. It is in nearly all cases the result of dis- 
ease, which is located sometimes within the cranium, but often in other 
parts of the system. 

Causes. — The diseases within the cranium which most frequently 
produce serous effusion are the meningeal inflammations, both simple 
and tubercular, tumors or other causes which obstruct the venous circu- 
lation, and hemorrhagic effusion ending in the formation of cysts. Pro- 
longed passive congestion often ends in transudation of serum through 
the coats of the capillaries. Therefore, all those causes of congestion, 
except such as have a transient or momentary effect, may be regarded 
as causes of serous effusion. 

Among the diseases external to the cranium which produce serous 
effusion within or upon the brain, may be mentioned retropharyngeal 
abscess, tuberculization or inflammation of the bronchial glands, scarlet 
fever, and certain affections of an exhausting nature, especially pro- 
tracted diarrhoeal maladies. In at least five cases which have fallen 
under my notice, and in which post-mortem examinations were made, 
the cause was enlarged tubercular bronchial glands, which, by pressure 

1 Medical Times and Gazette, 1860. 
29 



450 ACQUIRED HYDROCEPHALUS. 

on the venae innominatge, so retarded the flow of blood from the brain 
as to cause congestion and eifusion. The causative relation of these 
glands to cerebral congestion is more fully described in our remarks in 
reference to this disease. 

Dropsy of the brain is common in protracted infantile diarrhoea, as, for 
example, in advanced cases of intestinal catarrh of the summer months 
in the cities. It is preceded and accompanied by passive congestion of 
the cerebral veins and sinuses, due in part to feebleness of circulation 
in consequence of the exhausted state of the patient, and in part to 
wasting of the brain, which always give rise to more or less passive 
congestion, unless in young infants, in whom the cranial bones become 
depressed and override each other. Dropsy of the brain, resulting 
from scarlet fever, and that peculiar circumscribed dropsy which results 
from hemorrhagic effusions, are described elsewhere. 

A few cases have been related by different observers, Abercrombie 
among others, in which dropsy of the brain seemed to be essential. 
Nothing abnormal was observed, with the exception of serous effusion. 
But the reports of such cases are, for the most part, meagre; and, as 
Barrier has well said, we are not to accept such cases as examples of 
essential dropsy of the brain, unless the post-mortem inspection be so 
complete as to render it certain that there was no pathological state 
which might cause the dropsy. 

Anatomical Characters. — Acquired hydrocephalus usually occurs 
after the cranial bones are firmly united, and, therefore, the shape of 
the head is not materially altered. If it occur at any early age, before 
there is free union, there may be expansion of the cranial arch, as we 
sometimes observe in the circumscribed hydrocephalus resulting from 
hemorrhage. The effusion in acquired hydrocephalus occurs over the 
surface of the brain, in the subarachnoid space, or in the lateral ven- 
tricles. In the dropsy of protracted diarrhoea! maladies, I have rarely 
failed to find the liquid over the whole superior surface of the brain as 
well as at its base. 

The quantity of fluid in this disease is not large. In the majority 
of cases it does not exceed four ounces, and is often much less. It is 
transparent, or it has a slightly yellowish tinge. The membranes of the 
brain sometimes present their normal appearance, but in other cases 
they are injected. The brain itself, in some instances, has an injected 
appearance from passive congestion of the veins and capillaries ; but in 
others, when there has been more or less compression of the brain, there 
is no more than the ordinary, or even less than the ordinary vascularity, 
and the convolutions are somewhat flattened. 

Symptoms. — The symptoms of the pathological state which gives 
rise to the dropsy, precede and accompany those which are referable to 
the dropsy itself. The dropsy declares itself by symptoms which are 
alarming from the first. 

In children old enough to speak, or manifest intelligence, there may 
be at first complaint of headache. The child is irritable, its mind con- 
fused or wandering at times, or there is actual delirium. After a time 
drowsiness occurs. The head seems too heavy for the body, and is buried 
in the pillow. In fatal cases the features become pallid, the pupils 



SYMPTOMS. 451 

sluggish, and perception and consciousness are gradually lost. The 
child lies in profound sleep, which increases. There are now often con- 
vulsive movements partial or general, and these soon end in coma, in 
which the patient dies. 

The following was an interesting case of acquired hydrocephalus, which 
seemed to result from subacute meningitis. The patient was seen by 
several physicians, and the diagnosis was for a long time doubtful. 

Harry R. L., of healthy parentage, was well till the summer of 1876, 
when he was nearly at the close of his third year. At this time he was 
observed to be feverish and fretful and his features were flushed at times. 
He also complained almost daily of pain in the top of his head, which 
pain was intermittent, and these attacks of headache occurred for at least 
six months, perhaps longer. There had been no backwardness in den- 
tition, and no symptoms of rachitis or struma, and his nutrition was 
good even after the commencement of the present malady. 

In February or March, 1877, his stomach became irritable, so that 
he vomited often during the following months, and about the same time 
he began to lose the use of both legs — a progressive paralysis — and his 
bowels became constipated. Both urination and defecation were slug- 
gishly performed. 

In July, 1877, he ceased to walk, and he has not been able to stand 
since. 

On March 29, 1878, the following records were made: Xo improve- 
ment, but gradual increase of most of the symptoms; lies constantly; 
moves his limbs slowly, and infrequently, but completely, and sensation 
appears to remain in all of them ; his eyes are clear and pupils mod- 
erately dilated, but without vision — how long 
his sight is lost is not known ; axis of eyes not 
depressed or otherwise changed, and parallelism 
retained; the cranium, which during the first 
year of his sickness underwent little change, 
has expanded rapidly during the last six months ; 
the enlargement is most marked above the ears ; 
the occipitofrontal circumference is represented 
in the accompanying diagram; this circumfer- 
ence measures twenty-one- and a half inches, of 
which nine and three-quarters are in front of 

ears, and eleven and one-third inches posterior to ears; distance over 
vertex from one auditory meatus to the other, fifteen and one-quarter 
inches. The anterior fontanelle is observed to be open, though small, 
the diameter being about one-fourth or one-third of an inch; it is not 
elevated, and the surrounding edge of bone is flexible. 

This patient lived till near the close of 1880, without material change 
in symptoms, and with moderate but progressive increase in the size of 
the head. At the autopsy measurements were again made, but they 
have been mislaid. The enlargement was found to be due to the pres- 
ence of about three pints of straw-colored serum in the lateral ventricles, 
which had been changed into a large cavity. There was nothing to in- 
dicate any other disease. From the history and appearances we inferred 
that the hydrocephalus had been due to a mild meningitis occurring 




452 MENINGITIS. 

in the third year. The appearance and state of the encephalon were 
precisely like those in ordinary congenital hydrocephalus. 

Prognosis. — Acquired hydrocephalus commonly ends unfavorably. 
The prognosis depends not only on the quantity of liquid, but on the 
nature of the cause. If the cause be venous obstruction within the 
cranium or thorax, as we have no means of removing it, death is inevit- 
able. If it be an exhausting disease, as entero-colitis or scarlet fever, 
although the case is not absolutely hopeless, the prospect is still unfavor- 
able. It is only favorable when the quantity of effused fluid is small, 
the system not much reduced, and the primary disease mild. "When 
acquired hydrocephalus arises from meningeal apoplexy, the case is 
usually chronic. The symptoms and termination of this form of the dis- 
ease are very similar to those in congenital hydrocephalus. 

Treatment. — The treatment in acquired hydrocephalus must vary 
somewhat in different cases, according to the nature of the disease on 
which it depends. I shall indicate the treatment, in part at least, in the 
description of these diseases. Occasionally the condition of the patient 
is such that there is little to encourage us in the employment of any 
remedial measures. In vigorous children, if acquired hydrocephalus 
occur in connection with symptoms which indicate too active a circula- 
tion, moderate abstraction of blood from the temples at an early period 
may be useful, but cases requiring such depletory measures are rare. 
These cases require cold applications to the head; the bowels should be 
opened, and derivatives should be applied to the feet and back of the 
neck. 

If the congestion be of a passive character, as when the circulation is 
obstructed by tumors or otherwise, benefit may still be derived from 
cold applications to the head, and derivatives to other parts. In most 
cases of suspected dropsy of the brain, unless the patient be in such a 
hopeless state that all treatment is obviously futile, vesication should be 
produced behind the ears. I prefer cantharidal collodion for this pur- 
pose. In addition to this treatment, diuretics should be employed, 
unless there be too great prostration, or the course of the disease be so 
rapid that no benefit can result in consequence of the tardy action of 
these agents. The best diuretics are the acetate of potassium and iodide 
of potassium. 



CHAPTEE IX. 

MENINGITIS, TUBERCULAR AND NON-TUBERCULAR. 

The most interesting and important disease of the cerebro-spinal 
system in early life, is that which is now designated meningitis. It is 
not infrequent. The mortuary statistics of this city show that it is the 
cause of death in from one in twenty-five to one in fifty of the entire 
number of deaths, the proportion varying somewhat in different years. 



MENINGITIS. 453 

In 1768, the attention of the profession was particularly called to 
this disease by Dr. Whytt, of Edinburgh. This observer, and the path- 
ologists succeeding him, forming their opinion of meningitis from its 
most prominent anatomical character, namely, serous effusion, believed 
it a dropsy. They accordingly designated it acute hydrocephalus. 
During the last forty years the profession have come to regard the dis- 
ease as inflammatory, and hence the name by which it is now known, 
and which is believed to express its true pathological character. 

Sometimes meningeal inflammation in children occurs without tuber- 
cles. In other instances it results from the presence of tubercles, and 
in most, if not in all such patients, there are tubercles in or under the 
meninges, which excite the inflammation in the same manner as in the 
lungs they cause pneumonitis or pleuritis. Therefore two forms of 
meningitis are recognized, namely, tubercular and non-tubercular. 

Prior to 1868 I had preserved records of forty-five fatal cases of 
meningitis, some occurring in my private practice, and the remainder in 
institutions of this city with which I have been connected. Post- 
mortem examinations were made and recorded in thirteen of them. 
Twenty-five were under the age of one year, of which fifteen were ap- 
parently well when the meningitis commenced, belonging for the most 
part to healthy families ; three were feeble and cachectic, but appar- 
ently without tubercles ; and five had miliary tubercles in various organs, 
as shown by post-mortem examination. The condition of the other two 
as regards the probable presence of tubercles, was not recorded. 

Of the twenty who were over the age of one year, the majority, 
namely, thirteen, presented a decidedly cachectic or strumous aspect 
before the meningitis occurred, and a considerable number had symp- 
toms of pulmonary tubercles. These statistics, as far as they go, show 
that non-tubercular meningitis predominates under the age of one year, 
and I may add eighteen months, while over that age the tubercular 
cases are in excess. 

M. Bouchut, speaking in reference to tubercular meningitis, says as 
follows : " Up to this period it was not believed that this disease existed 
in young children, for no mention is made of it in the works of Denis 
and Billard. Still its existence at this age is, nevertheless, incon- 
testable. MM. de Blache, Guersant, Rilliet and Barthez, and Barrier 
have observed several examples of it, and I have collected six cases of 
this disease in the practice of M. Trousseau. The youngest child was 
only three months old, and the eldest had arrived at the end of his 
second year. No statistics can be based on so small a number of facts ; 
the only value they have consists in their overruling an opinion falsely 
accredited in medical science." I have witnessed the post-mortem of 
five cases of tubercular meningitis occurring; in children under the age 
of one year, as is seen from the above statistics, and the age of one of 
these was only four months. In two, perhaps I should say three, of the 
five the presence of tubercles in the meninges was not positively demon- 
strated ; but in all of the five cases miliary tubercles were present in the 
lungs and other organs, so that I did not hesitate to consider the men- 
ingeal inflammation of a tubercular character. 

In patients over the age of eighteen months, although the proportion 



454 MENINGITIS. 

of tubercular to non-tubercular cases is larger than under this age, the 
excess is not so great, according to my statistics, as the remarks of some 
observers lead us to suppose. There can be no accurate statistics of 
tubercular meningitis without careful post-mortem examination of the 
state of the brain and other organs in each supposed case, and this ex- 
amination sometimes shows the meningitis to be non-tubercular, -when 
the symptoms and signs had indicated its tubercular character. As an 
example, may be mentioned a case which occurred in the children's 
service of Charity Hospital, in March, 1868. The infant died at the 
age of twenty months, having had a cough of moderate severity at least 
three weeks before death, and symptoms of meningitis about four days. 
It was considerably wasted, and was supposed to have tuberculosis. At 
the autopsy, no tubercles were found in any part of the body, but portions 
of both lungs were hepatized. A fibrinous deposit, varying in thick- 
ness, was found over the pons Varolii, the optic commissure, along the 
fissures of Sylvius, over the superior surface of the anterior half and also 
upon the superior lobe of each cerebral hemisphere. As the examina- 
tion failed to discover any tubercles, the meningitis was considered 
non-tubercular. Those who make these examinations, failing to find 

7 o 

tubercles in the lungs and other organs in which they usually occur, 
should examine the lymphatic glands, since cheesy glands may be the 
cause of the formation of tubercles in the meninges, while the organs of 
the trunk remain unaffected. The presence of cheesy glands in the 
absence of visceral tubercles, and with granulations upon the meninges, 
small, covered with fibrin, and of a doubtful character, goes far toward 
establishing the tubercular nature of the meningitis. Since the cases 
w r hich furnished the above statistics were observed, now more than thir- 
teen years, I have been led by a more extended experience, and especi- 
ally by the observation of cases in the New York Foundling Asylum, 
where there is ample material, to regard not only the presence or 
absence of tubercles, but also of caseous substance, as the proper test 
of the form of meningitis. Not a few that seem at first to have non- 
tubercular meningitis will be found, on more thorough examination, to 
have caseous substance in some part, the result of a preexisting inflam- 
mation ; and if we regard the inflammation of the meninges occurring 
under such circumstances as tubercular, the relative proportion of tuber- 
cular cases will be considerably augmented. The following is an 
example. When on duty in the asylum in August, 1881, an infant 
about one year old died of meningitis. No tubercles were observed in 
the fibrin at the base of the brain, and along the fissures of Sylvius but 
one inflammatory nodule (cerebritis) as large as a chestnut, with sup- 
puration inside, w T as found at the summit of one hemisphere. No tuber- 
cles could be detected in any of the organs of the trunk, unless a few 
whitish spot 3 in the spleen were of this nature, but the bronchial glands 
were cheesy and softened, and the middle lobe of the right lung also 
contained cheesy substance. It seemed to me probable that some of 
this degenerated product taken up by the vessels had lodged in the 
meninges and produced the tubercular neoplasm there, w T hich was 
hidden under the fibrin. (See article Tuberculosis.) 

Age. — The following table gives the age in meningitis, tubercular 
and non-tubercular, in forty-two cases in my collection : 



PATHOLOGICAL ANATOMY. 455 

Cases. Age. 

1 2 J weeks. (Autopsy.) 

2 ........ 2 months. 

20 From 3 to 12 months. 

10 From 1 years to 2 years. 

5 ....... From 2 years to 5 years. 

4 Over 5 years. 

42 

Rilliet and Barthez have also published statistics of the age in men- 
ingitis. Their cases were observed chiefly in hospital practice, and the 
result is somew T hat different. 

In thirty-two cases of non-tubercular meningitis observed by these 
authors, eight were under the age of one year, six from two years to 
five, and eighteen over the age of five years. In ninety-eight cases of 
tubercular meningitis, two were under the age of one year, fifty-one 
between the ages of one year and five, thirty-eight between the ages of 
five years and ten, and seven between ten and fifteen years. 

Pathological Anatomy. — This differs considerably in different 
cases. The dura mater is usually unaffected or is affected secondarily. 
In many cases it retains its normal appearance, its internal surface 
remaining smooth and polished, while in others it is more or less in- 
jected, and its internal surface dim or lustreless. The free surface of 
the pia mater, formerly designated the visceral arachnoid, is in a great 
part of its extent unchanged, but is often hyperremic, or dry and cloudy, 
or opaque, over the seat of the inflammation. Exudation does not occur 
upon the free surface of the pia mater, however intense the inflammation. 

In meningitis, tubercular and non-tubercular, the inflammatory 
action occurs in the pia mater. In its meshes, or underneath them, 
those lesions result which characterize the disease, and to wdiich other 
lesions are secondary. Tubercular meningitis is most frequently basilar, 
or is basilar chiefly and primarily, although the inflammation may 
extend along the sides of the hemispheres. The meningitis is ordi- 
narily most intense around the pons Varolii in the subarachnoid space 
and along the fissures of Sylvius, for the tubercular neoplasm occurs 
chiefly at the base of the brain and along the vessels. In non-tuber- 
cular meningitis, the inflammation may also occur at the base. It may 
in young infants be quite diffuse, and of little intensity in any one 
place, producing, in addition to hyperemia of the pia mater, slight 
cloudiness and a moderate or slight escape of leucocytes from the blood, 
these (pus-cells) being perhaps visible only under the microscope. In 
meningitis due to extension of inflammation from an otitis media, the 
inflammatory action is intense, confined to the portion of the meninges 
nearest the ear, and is often attended by inflammation of the adjoining 
brain-substance, with perhaps the formation of an abscess. If the cause 
be exposure to the sun's rays, the meningitis is at the summit of the brain. 

The exudation of fibrin is greatest along the course of the vessels, 
and in the depressions between the convolutions, and the opacity is 
most marked in these situations. Pus, when present, is often semi- 
solid, from the small proportion of liquor puris which it contains, even 
in recent cases. If the disease have continued several days, the liquor 
puris may be mostly absorbed, and the pus-cell becoming shrivelled, 



456 MENINGITIS. 

irregular, and aggregated, may resemble closely the cheesy transforma- 
tion of tubercle-cells. 

The fibrinous exudation presents features of interest. It does not 
usually attain much thickness, but by its opacity it conceals from view 
the brain underneath. If it occur in the fissures of Sylvius, the ante- 
rior and middle lobes are united by it. It is usually infiltrated through 
the substance of the pia mater. Sometimes little masses of variable 
size, often not as large as a pin's head, appear at the point of inflamma- 
tion. These masses are firm, of a whitish color, or a light yellow, and 
their number varies in different cases. They consist of a firm, homo- 
geneous substance, containing granular matter, and cells which often 
bear a close resemblance to tubercle-corpuscle, but are distinct. These 
corpuscular bodies are plastic nuclei or plastic cells, often shrunken. It 
is seen, then, that there are two morbid products which may be mis- 
taken for tubercle : one, pus which has been in great measure deprived 
of its liquid element, and which may resemble cheesy tubercular matter ; 
the other, plastic nuclei collected in little bodies, so as to resemble the 
ordinary form of crude tubercle. I once carried to one of the best micro- 
scopists and pathologists of this city some of the exudation from a case 
of meningitis, the cellular element in which could not readily be distin- 
guished from shrunken tubercle-corpuscles. The exudation was from a 
child two years and eight months old, with good health previously to 
the meningitis ; without tubercles in any part of the body, with parents 
healthy, and with no predisposition to tubercular disease. The micro- 
scopist, not knowing the history of the case, or character of the family, 
and ignorant, like all of us at that time, of the true tubercle cell, pro- 
nounced the exudation tubercular after a careful examination with the 
microscope. Bouchut says : "The whitish miliary granulations which 
are observed on the surface of the pia mater have a certain consistency 
and tenacity which render them difficult to tear with the needles used 
for the preparation for the microscope. These bodies are formed: 1. 
Of fibro-plastic elements, whether nuclei or fusiform fibres ; oval-shaped 
cells are generally present, but not always. The nuclei are oval or 
spherical, generally very small — that is to say, they hardly exceed in 
diameter 0.008 mm. to 0.009 mm. The presence of these little spheri- 
cal nuclei must be insisted on, because, with a less power than 550 
diameters, it would be sometimes impossible to establish the differences 
which separate them from the elements of tubercles ; the fusiform fibres 
are small and rare. 2. There exists a considerable quantity of amor- 
phous homogeneous matter, in which minute granulations are scattered ; 
it is very dense, and keeps the other elements strongly united together, so 
that it is difficult to isolate them completely. 3. Vessels are very rarely 
observed ; the fibres of cellular tissue are also rare, or altogether wanting." 

There being two microscopic elements which are distinct from tubercu- 
lar formations, but are liable to be mistaken for them, namely, shrivelled 
pus-cells and plastic nuclei, more or less altered, it is seen, in part at 
least, why the old writers, and some of a more recent date, either hold 
that all meningitis is tubercular, or that there are comparatively few 
non-tubercular cases. 

On the other hand, there are cases of true tubercular meningitis 



PATHOLOGICAL ANATOMY. 457 

which, even with a pretty careful microscopic examination, might be, 
and probably often have been, regarded as non-tubercular. In order to 
an understanding of this subject, I may be permitted to repeat certain 
facts already stated in the article on tuberculosis. The views of path- 
ologists in reference to what is the primary form of tubercle, and what 
is and what is not tubercular matter, have recently undergone a great 
change. It is now known that the tubercle-cell is a round, pale, slightly 
granular cell, identical in appearance with the normal cell of the lym- 
pathic glands, being on the average somewhat smaller than the white 
corpuscle of the blood ; that it is produced mainly from the nuclei of 
the connective tissue by proliferation ; that it is vitalized like other cells, 
and, of course, has functional activity ; that the true, the living cell, 
is found only in the so-called gray, semi-transparent tubercle. It is 
furthermore known that what has heretofore been considered the tuber- 
cle-cell, namely, the irregular, sometimes angular, sometimes oval cell — 
without, indeed, any typical form — may be a dead, shrivelled, and altered 
tubercle-cell, or a dead, shrivelled, and altered pus or other cell. If, 
therefore, such cells are found in the meshes of the pia mater, we cannot 
determine from the microscope their true character. We can only form 
our opinion in reference to their nature from concomitant circumstances, 
or from discovering in connection with them the true tubercle-cell. 
Those products which have been designated crude tubercle and tuber- 
cular infiltration, contain these shrivelled cells, or shrivelled nuclei ; and 
they may have a tubercular origin, or, on the other hand, an inflamma- 
tory origin, without either the tubercular product or diathesis. 

In the tuberculosis of young children I have found in a large propor- 
tion of cases in which I have had an opportunity to make post-mortem 
examinations, miliary tubercles disseminated through the lungs, and per- 
haps other organs, in small masses, many of them not larger than a pin's 
head, and some occurring as mere specks scarcely visible. These minute 
tubercular formations have ordinarily been semi-transparent, and some- 
times even transparent like minute drops of water, and containing the 
true and unchanged tubercle-cell. Now if in such a case meningitis 
occur, we may find the tubercle-cell in or with the fibrin at the base of 
the brain. But failure to find it, even with protracted microscopic ex- 
amination, does not prove its absence from this locality, for I consider 
it almost impossible to discover in the midst of the fibrinous exudation 
such minute points of tubercular matter as are seen in the lungs, liver, 
or elsewhere. 

The pia mater is often firmly adherent to the brain at the seat of in- 
flammation, so that on raising it a portion of the brain may be detached 
and removed with it. The extent of the inflammation varies much in 
different cases. There may in extreme cases be pretty general inflam- 
mation of the pia mater. In cases of such extensive meningitis, the 
symptoms are usually severe and the course of the disease rapid. 
Thus, in the month of April, 1866, a girl eleven years of age, in the 
Protestant Episcopal Orphan Asylum of this city, had complained occa- 
sionally of dizziness, but was otherwise in good health, cheerful, and 
with excellent appetite, till Thursday, when she was affected with ver- 
tigo, more persistent than previously, and with headache. At 2 P. M. 



458 MENINGITIS. 

on the following day she was seized with general convulsions, and con- 
tinued insensible or nearly so, with occasional convulsive movements, 
till Monday, when she died comatose. The pia mater at the vertex, 
sides, and base of the brain had a cloudy appearance, and underneath 
it, in places, was a thick, creamy substance in small quantity, which, 
examined by the microscope, proved to be pus, the largest amount being 
near the pons Varolii. There was no tubercle under the meninges or 
elsewhere, and no appreciable fibrinous exudation. The meningitis, 
though of brief duration, was nearly general. 

The only additional lesions noticed were moderate congestion of the 
brain and an increase in the quantity of the cerebro-spinal fluid. 

If the disease be protracted three or four weeks, which is rare* or even 
less time, the exuded substance may undergo further changes, such as 
occur in simple exudations in other parts of the system. Thus, on the 
30th of April, 1860, we made the post-mortem examination of an infant 
at the Nursery and Child's Hospital, who had symptoms of cerebral dis- 
ease, it was stated for several weeks, but the exact time was not ascer- 
tained. Prominent among the symptoms referable to the cerebro-spinal 
system toward the close of life were the hydrocephalic cry and rigidity 
of the neck. The appearance at the autopsy was remarkable. The an- 
terior half of the brain was completely encased in a deposit which had 
nearly the appearance of lard. It filled the fissures of Sylvius, and 
appeared slightly on the anterior aspect of the cerebellum. Examined 
under the microscope, this substance was found to contain numerous 
cells, among which could be distinguished some resembling pus-cells, 
but nearly all had undergone more or less fatty degeneration. Here 
and there was seen a large cell containing numerous small oil-globules, 
the compound granular cell of pathologists. 

The brain itself in meningitis is usually hypersemic. On making an 
incision through it, red points are seen upon the cut surface, which in- 
dicate the seat of the congested vessels. The inflammation rarely 
extends to the walls of the ventricles, but the choroid plexus is injected. 
In exceptional instances pus or fibrin is found in the lateral ventricles. 
In the infant, two and a half weeks old, whose case has already been 
alluded to, about two ounces of purulent fluid escaped on opening the 
left ventricle. A small amount of liquid of a similar character was con- 
tained in the right ventricle. The distention of the lateral ventricles 
with serum is one of the common results of meningitis. This fluid is 
clear or straw-colored, or it is turbid in consequence of being mixed 
more or less with the softened brain-substance. The quantity does not 
exceed, two, three, or four ounces, and is often not more than one ounce 
or an ounce and a half. The distention of the two ventricles is ordin- 
arily uniform, as they are united by the foramen of Monro, but now 
and then one ventricle is found more distended than the other. If there 
be considerable effusion, the brain is compressed and the convolutions 
have a flattened appearance, unless the cranial bones are still separated 
so as to yield to the pressure. If the sutures and fontanelles be open 
the cranial arch is expanded, sometimes quite perceptibly to the eye. 
From the same cause the anterior fontanelle, if open, is elevated. The 
foramen of Monro is enlarged according to the amount of effusion, and 



causes. 459 

the portions of the brain which separate the ventricles are sometimes 
lacerated. In many cases the cerebral substance surrounding the lateral 
ventricles is softened. The softening is found in all degrees, from the 
least appreciable deviation from the normal consistence to a state of 
diffluence, so that the brain presents the appearance of cream. Hypo- 
theses have been advanced to explain the cause of this change in consis- 
tence, which are not entirely satisfactory. Whatever the explanation, 
the fact is attested by all observers, though there are exceptional cases. 
Thus Dr. "West has records of the condition of the brain in fifty-nine 
cases, in thirty-seven of which there was considerable softening, and in 
the remaining twenty-two the consistence was normal. 

Since a majority of the cases of meningitis in children are basilar, 
and portions of all the cerebral nerves lie at the base of the brain, it is 
easy to understand why the functions of these nerves are so seriously 
impaired in this disease. Compression of these nerves, or extension of 
inflammation to their sheaths, affords explanation of many of the symp- 
toms, as the sighing respiration, abnormalities of the eye, etc. 

Although the above remarks relating to the anatomical characters of 
meningitis are applicable to a large majority of the cases, I must confess 
that I have sometimes been disappointed at the autopsies of young in- 
fants who died with all the symptoms of meningitis in not finding more 
lesions. Moderate hyperemia of the pia mater, its slight opacity or 
cloudiness at the base of the brain or elsewhere, with the presence of a 
few wandering white corpuscles, without any fibrinous exudation, with 
no increase of liquid external to the brain, but a considerable increase 
of it in the lateral ventricles, and hyperemia of the choroid plexus, with 
nearly natural appearance and consistence of the brain, have in some 
instances been the only lesions when I had expected to find marked 
anatomical changes. 

I am fully convinced from my own observations that, in some instances, 
physicians who supposed that they were treating tubercular meningitis, 
and at the autopsies discovered within the cranium tubercles, without 
any inflammatory lesion, but with a larger increase of the cerebro-spinal 
liquid, have been treating cases in which in addition to the meningeal 
tubercles, which were latent, the bronchial glands were tubercular and 
cheesy, so that by their increased size they compressed the venae in- 
nominatse within the thorax, thus preventing the free flow of blood from 
the brain, and causing, as I have elsewhere stated, cerebral and menin- 
geal congestion, with more or less transudation of serum, but with no 
meningitis. 

Causes. — The causes of non-tubercular meningitis are not fully ascer- 
tained. Active cerebral congestion frequently occurring, however pro- 
duced, appears to be one of the common causes in young infants. In 
at least three instances I have known meningitis occur in infants be- 
tween the ages of four and eight months, after severe and protracted 
bronchitis, which had been attended with the usual heat of head. The 
disappearance of eruptions upon the scalp, at or immediately before the 
commencement of the meningitis, has also been observed. I have wit- 
nessed it at the commencement of non-tubercular meningitis, as well as 
of meningitis which, if not tubercular, occurred at least in a decidedly 
scrofulous state of system. 



460 MENINGITIS. 

The direct effect of the solar rays upon the head, and the prolonged 
action of a high atmospheric temperature, even without direct exposure 
of the head to the sun, are common causes during the summer months 
in New York City. I once attended a child with this disease who had 
been much exposed bareheaded to the direct rays of the sun in August 
and September, and at his death, which occurred toward the close of 
the hot weather, found hyperemia, opacity, and fibrinous exudation in 
the pia mater at the summit of the brain, while the base of the brain 
seemed nearly or quite normal. 

Dr. Soltmann, 1 of Breslau, reports three cases, in which intense cere- 
bral hyperemia, and probably meningitis, occurred from solar heat. In 
all three children the attack was sudden, the febrile movement and heat 
of head intense, and the progress rapid. The first had convulsions, the 
second automatic movements, and the third, the oldest, aged four years, 
when able to speak, complained of violent headache. 

The statistics of New York City show that congestive and inflamma- 
tory maladies of the brain and its covering are more common during 
July and August, which are the months of maximum atmospheric heat, 
than in other months of the year. For example, in July and August, 
1875, one hundred and sixty-seven died of these maladies, or one in 
every nine and eight-tenths who died from local disease, while during 
the entire year only seven hundred and ten died from the same, or one 
in every fifteen who perished from local diseases. 

July, 1876, in New York City, was characterized by excessive and 
long-continued atmospheric heat, the temperature of the Central Park 
Observatory in the shade never falling below 61°, though never above 
98°, and having a mean of 82.9° There was also unusual dryness of 
the atmosphere, since during the entire month prior to July 30th, there 
were only fourteen hours of rain, with a rainfall of 0.77 of an inch, and 
the average atmospheric humidity w T as represented by 65, saturation 
being denoted by 100. During this month I treated in my private 
practice four fatal cases, all between the ages of two and seven years, 
which I diagnosticated meningitis, none of them presenting any symp- 
toms of otitis or tuberculosis. It would seem that the atmospheric heat 
had much to do with the development of the disease in these cases. One 
died in two days, but in the others there was the usual duration. 

A not infrequent cause, especially among the strumous families of 
cities, is otitis media, and caries of the petrous portion of the tempo- 
ral bone, the inflammation extending to the meninges. Since tuber- 
cular meningitis is due to the irritating effect of tubercles in or under 
the pia mater, it usually occurs where tubercles are most abundantly 
developed, that is, at the base of the brain, and along the course of the 
vessels in the inter-gyral spaces. The inflammation is commonly 
excited when they are still small, even minute. 

Premonitory Stage. — Meningitis is usually preceded by symptoms 
which, if rightly interpreted, are of the greatest value. In most cases 
of this malady which I have seen, there was a prodromic period, vary- 
ing from a few days to several weeks. The symptoms of this period 

1 Jahrbuch f. Kinderkrank. for October, 1875. 



SYMPTOMS. 461 

are obscure, and are liable to be mistaken for those of other and distinct 
affections. 

The child in whom meningitis is approaching loses his accustomed 
vivacity and cheerfulness. He has a melancholy and subdued appear- 
ance, being quiet for a few minutes, and then fretful, without apparent 
causes. He can sometimes be amused by his playthings or companions 
for a brief period, when he turns from them with evident displeasure. 
Unexpected and loud noises and bright lights are evidently painful. If 
old enough to describe his sensations, he complains of transient dizzi- 
ness, and at other times of headache. His ill-humor, if his wishes are 
not immediately gratified, or if they are denied, is often scarcely endur- 
able on the part of friends, who are ignorant of the cause. There is 
great difference, however, in different cases, as regards this symptom. 
Some are inclined to be taciturn and quiet, while others are almost con- 
stantly fretting. The appetite is capricious ; at one time it is pretty 
good, at another it is poor or even entirely lost. The patient may take 
a few mouthfuls of food, or, if an infant, nurse for a moment, when his 
hunger appears satisfied, and he will take nothing more. The bowels 
are regular or inclined to constipation. The pulse is natural, or it has 
times of acceleration, especially in the latter part of the day and toward 
the close of the premonitory stage. The duration of this stage is very 
different in different cases. Upon an average it is perhaps about two 
weeks, but it is often longer. In tubercular meningitis the symptoms, 
both during the inflammation and previously, are often complicated by 
those which arise from tubercles in other parts of the system. 

Unless the prodromic period be of short duration, the effect of imper- 
fect nutrition is obvious before it closes. The flesh becomes soft and 
flabby, or there is emaciation, though generally slight. The patient 
loses his strength, becoming less able to stand or to walk, and more 
easily fatigued. Occasionally, especially in the non-tubercular form, 
premonitory symptoms are absent, or are slight and of short duration. 

Symptoms. — Dr. Whytt, living in the last century, when the ten- 
dency was toward refinement rather than simplicity in classification, 
divided meningitis into three stages, according to the symptoms, especi- 
ally the pulse. Many subsequent writers, following Whytt's example, 
have recognized three stages, based not upon the anatomical characters 
of the disease, but upon the succession of symptoms. Such division of 
meningitis is in great measure arbitrary, since in one case the same 
symptoms occur at an earlier period than in another. 

When the premonitory stage has passed, and inflammation is devel- 
oped, some of the symptoms which were previously present remain and 
are intensified, and other new and more characteristic symptoms appear. 
There are now fewer intervals of apparent improvement. The child 
is quiet, often lying with his eyes shut. If aroused, he has a w T ild ex- 
pression of the face, and is irritated by attempts to engage his attention 
or amuse him. He rarely smiles, or takes his playthings, or he notices 
them for a moment, when he turns away with disgust. During sleep 
there is often at first a placid expression of countenance, but when 
aroused he has the aspect of real sickness ; the eyebrows are sometimes 
contracted, as if from headache; the features wear a melancholy look, 



462 MENINGITIS. 

and are turned away to avoid the gaze of the observer or to shun the 
light. If the anterior fontanelle be open, it is observed to be prominent 
and pulsating forcibly. If consciousness be not lost, and the patient be 
of sufficient age, he complains of headache, or of pain in some part of 
the body. The tongue is moist, and covered with a light fur; the ap- 
petite is lost or poor; there is seldom much thirst; more or less nausea 
and constipation are present. As the inflammation continues, and 
usually within three or four clays from its commencement, symptoms 
arise which dispel all doubts, if there were any, as to the nature of the 
disease. The vital powers are now evidently beginning to yield. The 
surface generally is more pallid, and there is the curious phenomenon 
of the sudden appearance, and, after some minutes, disappearance, of 
spots or patches, or even streaks of active congestion upon the face, 
forehead, or the ears. These, having a bright red color, contrast 
strongly with the general pallor. Ordinarily they are irregularly cir- 
cular or oval, and from one inch to an inch and a half in diameter. A 
red spot or streak is also produced if the finger be pressed upon the 
surface or drawn forcibly across it. It continues a few minutes and 
then gradually fades. Trousseau calls attention to this fact as a diag- 
nostic sign. 

Another curious phenomenon is the variation in temperature. The 
face and limbs at one time feel quite cool, and after some minutes, with- 
out any excitement or other appreciable cause, the temperature rises, so 
that the surface is warm to the touch. 

Consciousness, in severe cases, may be lost at an early period. On 
the other hand, I have known it in a case of moderate severity to remain, 
though partially obscured, till within twenty-four or thirty-six hours of 
death. The patient will usually open his mouth for drinks which are 
placed to his lip, when there is no other evidence of intelligence, and 
when sight and hearing are evidently lost. 

The loss of the senses constitutes an interesting but melancholy fea- 
ture of the disease. Among the first unequivocal symptoms, and fre- 
quently the very first, are such as pertain to the eye. This organ 
should be watched from day to day when the diagnosis is uncertain. 
Deviation from its normal state affords evidence of meningitis. The 
pupils are seen to dilate or contract sluggishly by variations in the in- 
tensity of the light, or they are not of the same size w;ith those of another 
individual to whom the same amount of light is admitted. Sometimes 
the first perceptible deviation from the normal state is an inequality in 
the size of the pupils; while in others oscillation of the iris is observed. 
Later, when convulsions have occurred, the parallelism of the eyes is 
lost. After effusion has taken place, the pupils are commonly dilated. 
As death approaches, the eyes become bleared, and a puriform secretion 
collects in the inner angle of the eye and between the eyelids. This 
secretion is not abundant, but it is sometimes sufficient to unite the lids. 
The sense of hearing is probably lost as soon, or nearly as soon, as that of 
sight, but the sense of touch continues longer. The tongue is covered with 
a moist fur, unless near the close of life, when it is sometimes dry. The 
appetite is gradually lost, but often drinks are taken with apparent relish, 
even w T hen there is no other evidence of consciousness. There are two 



SYMPTOMS. 463 

symptoms pertaining to the digestive system which are rarefy absent, 
and which possess great diagnostic value; one is vomiting, the other 
constipation. In some patients, irritability of stomach begins at so early 
a period that it is really prodromic; it is rarely absent. Barrier col- 
lected the records of eighty patients with meningitis, and in seventy-five 
of these this symptom was present. It is due to the intimate relation 
existing between the stomach and brain, through the ganglionic sys- 
tem of nerves. The vomiting occurs without effort, and usually at 
intervals, for several days. It is a sudden ejection of the contents of 
the stomach, apparently without preceding or subsequent nausea. It 
contrasts, therefore, with the vomiting due to an emetic, which is attended 
by distressing symptoms. With some it occurs frequently, with others 
not more than two or three times daily. Commencing in the first stages 
of meningitis, or even prior to it, it occurs less often as the drowsiness 
becomes more profound, and finally ceases. Constipation is also present, 
usually from the commencement of the meningitis. It is one of the 
most constant and persistent symptoms, continuing through the entire 
sickness, unless relieved by medicine, or unless there be a coexisting 
diarrhoeal affection. Often, when diarrhoea precedes the meningitis, it 
ceases the moment the latter commences. The constipation in this dis- 
ease is easily overcome by purgatives. Several writers speak of retrac- 
tion of the abdomen as a sign of meningitis. A hollow or sunken ap- 
pearance of the abdomen, according to Golis, aids in distinguishing 
meningitis from fever. The anterior abdominal wall approaches the 
spine, so that the pulsations of the abdominal aorta are distinctly felt. 
Rilliet and Barthez, who have rarely observed this retraction except in 
cerebral diseases, attribute it to the state of the intestines rather than to 
the action of the abdominal muscles. 

The pulse in the first stages of meningitis is accelerated, or it is nearly 
natural during certain hours and afterward accelerated. When the dis- 
ease has continued a few days, often not more than three or four, the 
pulse undergoes a marked change. It becomes slower, and at the same 
time irregular. The irregularity usually consists in an intermittence 
of the pulse after each six or eight beats. Sometimes the force of the 
pulse varies, so that a feeble pulsation is succeeded by one of greater 
volume and strength. The decrease in the frequency of the pulse 
cannot fail to arrest attention. From 110 or 120 beats per minute in 
the first stage of the inflammation it often descends to a frequency even 
less than the normal adult pulse. At an advanced period, as death 
approaches, the pulse again becomes accelerated and feeble. 

The change in respiration is as decided as that of the pulse. In the 
beginning of the meningitis respiration is sometimes moderately acceler- 
ated, but in other cases it is natural. When the disease has continued 
a few days, the time usually varying from three or four to more than a 
week, a marked alteration occurs in the respiratory movements. Their 
rhythm, like that of the pulse, is changed. The breathing is irregular, 
intermittent, and accompanied by sighs. The change in pulse and res- 
piration corresponds with the loss of consciousness, and shows that the 
brain is becoming seriously involved. 

When the pulse and respiration undergo the changes which have been 



464: MENINGITIS. 

described, another prominent and grave cerebral symptom is often pres- 
ent, namely, convulsions. Its occurrence diminishes greatly the prospect 
of a favorable issue. The severity and extent of the convulsive move- 
ments vary in different cases. They may be partial or general. Their 
duration is often brief, but they recur three or four times through the 
day. They are preceded by cephalalgia in those old enough to express 
their sensations, and often by drowsiness. Each convulsive attack ends 
in still greater drowsiness. 

With this group of symptoms another should be mentioned. I refer 
to the hydrocephalic cry. At intervals the patient, without being dis- 
turbed, and without any change in symptoms, utters a scream or sharp 
cry, and immediately relapses into his former state. This cry is more 
common in the commencement of the meningitis than subsequentlv, and 
in many it is absent or is not a marked symptom. The glandular 
system participates in the general loss or derangement of function. 
Tears are seldom shed, even when the child is much irritated, and the 
urinary secretion is diminished. The small amount of urine passed 
sustains an important relation to the progress of the disease and the 
therapeutics. 

The patient usually lingers several days after the pulse and respira- 
tion are changed in the manner stated. The drowsiness becomes more 
profound, the vomiting ceases, as well as the convulsive attacks, and 
sensation and consciousness are entirely lost. But even in this state, 
if nutriment and stimulants be administered with regularity, the child 
often lives several days longer than appeared possible. At length in- 
creasing feebleness and rapidity of pulse and coldness of the face and limbs 
indicate the near approach of death, which occurs in a state of coma. 

The symptoms described above are such as we observe in ordinary 
cases of meningitis, and in the order which I have indicated. But he 
will be disappointed who expects that the above description will apply 
to all cases. 

Meningitis may be so violent and rapid that both the character and 
succession of symptoms are different from those which have been stated. 
Thus, I have related the case of a girl, who, with no prodromic symp- 
toms excepting occasional dizziness and slight headache, was taken sick 
on Thursday, had convulsions on Friday, and from this tkne continued 
either in convulsions or coma till her death on Monday. Again, even 
in cases of the usual duration and anatomical character, some of the 
most prominent symptoms upon which we rely for diagnosis may be 
lacking. The following was a case of this kind : 

Case. — On the 5th of April, 1862, I was asked to see a boy two years 
and eight months old, of healthy parentage, and who, during the preced- 
ing year, had been in uniform good health, but previously had had two 
or three severe attacks of sickness. His head was unusually large, and 
whenever much indisposed he often had synrptoms premonitory of convul- 
sions, which were always, however, prevented. 

One night, in the latter part of March, his parents noticed that his 
sleep was restless, but on the following day he seemed entirely well, and 
the restlessness at night was attributed to a late and hearty supper. On 
succeeding nights, however, he was restless, and, when questioned, com- 



SYMPTOMS. 465 

plained of pain in the abdomen. In a few days he was observed to be 
drooping in the daytime, and his appetite was not quite so good as pre- 
viously. He had continued in this way about a week when my first visit 
was made. 

The abdominal pain had at this time become more constant, but was 
never severe or accompanied by moaning. When asked where he felt 
sick, he placed his hand upon the epigastrium, pressure upon which was 
sometimes tolerated, but at other times painful. The following symp- 
toms were noted : tongue slightly furred, anorexia, thirst, constipation, 
scantiness of urine, no headache or unusual heat of head during any part 
of his sickness. He vomited at intervals from about the 7th to the 10th 
of April, when the irritability of stomach ceased, and there was no return 
of this symptom. 

About April 7th, the respiration was first observed to be irregular and 
sighing, and the pulse intermittent. These symptoms, so tardily devel- 
oped, were the first which indicated cerebral disease. He now lay most 
of the time in bed, with eyes closed, surface commonly pallid, with occa- 
sional rose-colored spots or patches upon the cheek or forehead. The 
pupils responded to light in the usual manner till near the close of life, 
but bright lights were painful ; the last two or three days of his life the 
left pupil was more dilated than the right. He had no convulsions or any 
spasmodic movement, and was conscious till within a few hours of death ; 
the mother states that there was unequivocal evidence of his recognition 
of her on the last day of his life. He died April 17th, nearly three weeks 
after the commencement of the disease, and ten days after the commence- 
ment of symptoms which were clearly referable to the brain. 

Autopsy. — Abdominal organs healthy, though epigastric pain had been 
so constant and prominent a symptom ; brain and its membranes some- 
what injected. The meninges covering the base of the brain from the 
most prominent part of the pons Varolii to the first pair of nerves pre- 
sented evidences of inflammation. There was such opacity of the pia 
mater in places as to conceal the brain from view. The anterior and 
middle lobes of each hemisphere were glued together by fibrinous exu- 
dation, and on the left side, along the fissure of Sylvius, was a thick 
deposit of the same character. The lateral ventricles contained about an 
ounce of clear serum, and about half an ounce escaped from the base of 
the brain. The foramen of Monro was considerably enlarged, and the 
brain-substance surrounding the lateral ventricles was softened. 

In this case it is seen that the prominent symptom, and, indeed, 
almost the only marked symptom in the first stages of the disease, was 
pain in the abdomen, and yet the abdominal organs were healthy. At 
the very moment when it was highly important that a correct diagnosis 
should be made, the evidences of cerebral disease were lacking. This 
case is, therefore, interesting on account of the variation in symptoms 
from those in the usual form of meningitis. There were no convulsions, 
and consciousness was retained as well as vision till near the close of 
life, and yet the lesions were such as are commonly present in menin- 
geal inflammation. It is in such cases that a wrong diagnosis is fre- 
quently made, to the injury of the patient and the reputation of the 
physician. 

Occasionally meningitis may continue so long as almost to justify its 
being called chronic, even when there is a large amount of exudation 

30 



-±d<3 MENINGITIS. 

upon the pia mater. In the few cases which end favorably, the symp- 
toms abate gradually. I shall describe more fully the termination in 
speaking of prognosis. 

Diagnosis. — It is of the utmost importance to diagnosticate menin- 
gitis in its first stages, since treatment, to be successful, must be com- 
menced early. Certain writers describe at length the means of diag- 
nosticating the simple from the tubercular form of the inflammation. 
Differential diagnosis is often difficult, and sometimes impossible ; but 
it matters little, practically,, whether 'the form of the disease be ascer- 
tained. On the other hand, it is very important, in order that the 
treatment be appropriate, to diagnosticate the premonitory or initial 
stage of meningitis from certain other affections not located within the 
cranium. Sometimes remittent or continued fever, or constitutional 
disturbances arising from irritation in the digestive system, simulate 
closely incipient meningeal disease, so that the greatest care and dis- 
crimination are required in order to make a correct diagnosis. Within 
a comparatively recent period I have known, in three different instances, 
experienced physicians of this city mistake commencing meningitis for 
fevers, not aware of the serious error they had made till the inflamma- 
tion had reached a stage from which recovery was impossible. In 
order to avoid error in the diagnosis in the premonitory or initial stage 
of meningitis, the physician should take time to observe the physiog- 
nomy, and note every symptom. More than one protracted visit is 
often required to remove doubt as to the exact pathological state. 

Meningitis is usually preceded and in its commencement accompa- 
nied by greater restlessness, fretfulness, intolerance of light, and a 
greater variation of symptoms than most other maladies. One familiar 
with the physiognomy of infancy and childhood, will discover in the 
features indication of greater suffering, of more serious sickness, than is 
commonly present in other maladies which simulate this. 

Sometimes the sudden disappearance of a chronic eruption upon the 
scalp will aid in the diagnosis. This is a sign of importance, taken in 
connection with the symptoms. Headache and vomiting, symptoms of 
early occurrence, should especially arrest attention, or, in absence of 
headache, pain of a neuralgic character in some other part. But we 
may repeat that familiarity with the symptoms of meningitis will not 
protect from error if the visits of the physician are hasty, and his exami- 
nations imperfect. When the eyes become affected, the respiration and 
circulation irregular, and especially when convulsive attacks begin, 
diagnosis is easy. In fact, an incorrect diagnosis would then be unpar- 
donable; but, unfortunately, if proper treatment have not been com- 
menced till this period, it will be of little service. 

Prognosis. — Meningitis is one of the most fatal maladies of early 
life. Whether the form be tubercular or not, if the initial stage have 
passed without proper treatment, death may be considered inevitable. 
Tubercular meningitis, however early recognized, is rarely amenable to 
treatment. M. Guersant 1 believes that recovery from the first stage 
of this form of meningitis is possible. " In the second stage," says 
he, " I have not seen one child recover out of a hundred, and even 

1 Diet. Med., t. xix. p. 403. 



PROGNOSIS. 467 

those who seemed to have recovered have either sunk afterward under 
a return of the same disease in its acute form, or have died of phthisis. 
As to patients in whom the disease has reached its third stage, I have 
never seen them improve even for a moment." The very few reported 
cases which resulted favorably may have been, as M. Guersant has inti- 
mated in the context, cases of the non-tubercular form. Rilliet and 
Barthez believe that in a few instances tubercular meningitis has been 
cured in its first stage, but they state also that it is apt to return. 

The prognosis in non-tubercular meningitis is not so unfavorable, pro- 
vided that treatment be commenced at a sufficiently early period. It is 
now generally admitted that it may not infrequently be averted, when 
threatening, and even arrested in its incipiency. In many such cases 
we cannot, from the nature of the disease, be certain that the diagnosis 
is correct. But when we see children relieved, who present precisely 
those premonitory and even initial symptoms which occur in meningitis, 
we must believe that at least some of them would have had the genuine 
disease if not relieved by the measures employed. That in its com- 
mencement, recovery is possible from non-tubercular meningitis is also 
obvious from the fact that a few recover even in the second stage, when 
there can be no error of diagnosis. 

Although a considerable proportion of patients with epidemic cerebro- 
spinal meningitis recover, even when the symptoms have been most 
grave, I have known only two recoveries from sporadic meningitis when 
it had reached that stage in which the functions of the brain and cranial 
nerves were impaired. One of these recovered with permanent loss of 
sight, the other with loss of hearing. Both seem to have ordinary in- 
telligence. Another case has been communicated to me, in which the 
patient, a little child, recovered completely, but for several months after 
the attack seemed nearly idiotic. 

Sometimes even in the second stage of meningitis, treatment properly 
employed is attended by amelioration of symptoms. Though such im- 
provement may serve to encourage physician and friends, it should not 
be the basis for a favorable prognosis unless it continue three or four days. 

Apparent improvement during a few hours or a considerable part of a 
day, is not unusual in those who finally die. Thus, in an infant whose 
bowels were previously confined, I have known the pulse and respiration 
to become more regular and the symptoms generally improve, though 
only for a brief period, by the action of a purgative. Dr. Watson says 
of the advanced stage of this disease, it is " often attended with remis- 
sions, sometimes sudden, and sometimes gradual, deceitful appearances 
of convalescence. The child regains the use of its senses, recognizes 
those about him again, appears to his anxious parents to be recovering, 
but in a day or two it relapses into a state of deeper coma than before. 
And these fallacious symptoms of improvement may occur more than 
once." 

Most fatal cases of meningitis terminate between the third or fourth 
and the twentieth day, the duration varying according to the extent and 
intensity of the inflammation, and the vigor and age of the patient. But 
there are cases in which it may continue much longer. It is surprising 
sometimes how long the patient lives, when the symptoms are such that 



468 MENINGITIS. 

death seems impending. Sensation and consciousness may be extin- 
guished, convulsions occur at intervals, and the surface have acquired 
almost a cadaveric aspect, and yet the patient lives on. Rilliet and 
Barthez say : " Often have we inscribed upon our notes death imminent, 
and been astonished the next day to find still alive children to whom we 
had scarcely allowed two hours of life." The symptom which I have 
found to be the most reliable prognostic of the near approach of death, 
has been a pulse gradually becoming more frequent and feeble, though 
other symptoms remain as before. This change in the pulse is usually 
very apparent during the last twenty -four hours of life. 

Treatment. — Such remedial measures should be prescribed during 
the premonitory stage as are calculated to relieve the fretfulness or irri- 
tability of temper and quiet the action of the brain, and, at the same 
time, produce a derivative effect from this organ. To this end the 
patient should be kept from all causes of excitement, and the bowels 
should be opened daily, if not naturally, by the use of proper medicines. 
A mustard foot-bath at night and occasionally through the day is useful, 
as it produces both a derivative and soothing effect. It will commonly 
produce a few hours' undisturbed rest, while all other measures except 
medicines fail. If dentition be taking place, and the gums are swollen, 
it has been the practice to employ the gum lancet, and still is with some 
physicians, but I for one have discarded its use for this purpose. Rest- 
lessness from dentition or restlessness premonitory of meningitis, re- 
quires decided doses of bromide of potassium, which will relieve the 
symptoms more effectually than the lancet. Three grains should be 
given to a child of six months, and four grains to one of ten or twelve 
months, and repeated if necessary in two to four hours. If symptoms 
indicate the near approach of meningitis, or its incipiency, the head 
should be kept constantly cool by a cloth wrung out of ice-water, or, 
better, an India-rubber bag containing ice, and cantharidal collodion 
should perhaps be applied behind one or both ears, over a space one 
inch in diameter. 

Many children who are threatened with meningitis are scrofulous. 
They have already shown symptoms of tubercular disease. They are 
perhaps, to a certain extent, emaciated, and may have been affected 
with a cough. The premonitory symptoms in these children indicate 
the approach of the tubercular form of meningitis,. and a more sustain- 
ing course of treatment is required than in those who are robust. To 
such children cod-liver oil may be profitably given, three times daily, 
together with the syrup of the iodide of iron, and perhaps the bromide. 
They should also be taken into the open air, w T ith proper precautions, 
and every hygienic measure should be employed which will be likely to 
invigorate the system without exciting the brain. 

Loss of blood is not, in general, required during the prodromic period 
nor in the disease. Those of a strumous cachexia, or those, whether 
strumous or not, who are under the age of two years, do not, unless in 
very rare instances, require depletion by leeches, much less by venesec- 
tion. There is one class of patients in whom the early loss of blood 
may doubtless be of service, namely, those, who in a state of robust 



TREATMENT. 469 

health are suddenly seized with inflammation. Leeches may then be 
applied to the head of the patient, if he be seen at an early period. 

Often, notwithstanding the measures employed, the patient grows 
worse, the symptoms become more continuous, others more alarming 
arise, and meningitis declares itself. Whatever the cause of the inflam- 
mation, and whatever modifications of treatment were required in the 
premonitory stage, on account of special indications, the purpose now is 
to subdue the inflammation by every resource in our art, which does not 
injure or too much prostrate the system. In former days calomel was 
largely employed as the main remedy in this disease, but when adminis- 
tered daily it has a very depressing effect, and it is to be borne in mind 
that in meningitis the vital powers progressively fail on account of the 
loss of appetite, vomiting, etc. In tubercular meningitis depressing 
treatment is, of course, strongly contraindicated, cases having occurred 
in which calomel was given at short intervals for several successive days, 
so as to produce a laxative effect, and though the meningitis seemed to 
be controlled, death occurred from exhaustion, or from some intercurrent 
affection, the result of the exhaustion. Thus in one case related to the 
class by a distinguished professor in New York City, fatal gangrene of 
the mouth supervened from the mercurial treatment, after the meningeal 
inflammation had apparently subsided. Although calomel during these 
last years, has been properly discarded as the main remedy, and its daily 
use rejected, nevertheless it is very useful as an occasional laxative in 
the more robust cases, if not given too near the iodide of potassium, 
and it is especially indicated as a derivative from the head in children 
of four or five years, who, previously hearty and strong, have become 
suddenly affected with meningitis, as from exposure to the sun's rays, or 
from an injury. But I repeat the belief that, in ordinary cases, calomel 
should never be employed, except as an occasional laxative. 

The two remedies upon which we must chiefly rely are the iodide of 
potassium and the bromide of potassium or sodium. While the bromide 
quiets the restlessness, prevents convulsions, and diminishes, there is 
reason to think, to a certain extent, the hyperemia, the iodide is useful 
as a sorbefacient, and it probably has some control over the inflamma- 
tion. The iodide or bromide can be given together or separately. 

The iodide should, like the bromide, be given early. If by a careful 
examination the absence of any other local disease, or constitutional 
disease, which might give rise to the symptoms be ascertained, and the 
symptoms indicate the meningeal disease, the iodide should be immedi- 
ately prescribed. Obscurity often hangs over meningitis at this early 
stage, but it is better to give the iodide, even if the diagnosis be wrong, 
and no inflammation have commenced, than to err on the other side, 
and withhold it in the initial period of the true disease, for it is not an 
injurious remedy like calomel, and to exert any marked curative effect 
it should be given in the commencement of the inflammation. An in- 
fant of the age of six to twelve months should take two grains every 
two hours, and older children a proportionate dose. At the same time 
the bromide should be given in doses twice as large as that of the iodide, 
if the indications for its use are present, namely, headache, restlessness, 
and symptoms which threaten eclampsia. The bromide is a harmless 



470 SPURIOUS HYDROCEPHALUS. 

remedy given frequently for a limited time. With the regular and con- 
tinued use of the iodide and occasional doses of bromide, the quantity 
of urine is in most cases largely increased. If the patient's condition 
do not soon begin to improve with such treatment there is no remedy. 

If convulsions occur the bromide should be given every ten or fifteen 
minutes till they cease. If they be not controlled by the bromide, an 
injection, per rectum, of three to five grains of hydrate of chloral in a 
teaspoonful of water should be used in addition. Compresses wrung 
out of cold water frequently applied to the head, or a bladder containing 
pounded ice, and separated by one thickness of muslin from the head, 
materially aid in reducing the meningeal hyperemia. Ergot, recom- 
mended by Brown-Sequard for its supposed effect in diminishing the 
hyperemia in the inflammatory diseases of the nervous centres, should 
also be employed as an adjuvant in the treatment of this disease. 

In the first stage of simple meningitis the diet should be mild and m 
moderate quantity, but in the tubercular form it should from the first 
be of the most nourishing kind, consisting of beef-tea, milk-porridge, 
etc. At a more advanced stage in both forms of the malady the most 
nutritious diet should be allowed, but alcoholic stimulants should not be 
given unless near the close of life when the vital powers are failing. 
The apartment should be cool and quiet. 



CHAPTEE X. 

SPUKIOUS HYDROCEPHALUS 

The disease known as spurious hydrocephalus might with more pro- 
priety be called spurious meningitis. It received its appellation at the 
time when meningitis of early life was believed to be essentially a hydro- 
cephalus, and was so called. Attention was first directed to this malady 
by London physicians of the last generation, particularly by Drs. 
Gooch, Abercrombie, and Marshall Hall, and little can be added to 
their description of its symptoms. 

Anatomical Characters. — This disease, though resembling menin- 
gitis, in certain of its phenomena, is not in its nature inflammatory, 
nor is it primary. It is the result of some malady often chronic, but 
occasionally acute, which has produced exhaustion, especially of the 
nervous system. When it commences, there is usually more or less 
emaciation, and the symptoms of the primary disease are present. To 
this disease the lesions pertain which are found in other organs beside 
the brain. 

The state of the brain in spurious hydrocephalus is not the same in 
all cases. In some there is no appreciable anatomical alteration in this 
organ. There is no apparent difference, either in the meninges or the 



SYMPTOMS. 471 

brain itself, from the condition which we often observe in those who 
have died of diseases which do not affect the cerebro-spinal system. In 
such cases the pathological state is simply deficient innervation, or if 
there be a structural change in the minute anatomy of the brain, 
pathologists have not yet discovered it. 

The following case, which occurred in the Child's Hospital of this 
city, is an example of this form of spurious hydrocephalus: 

Case. — A female infant, six months old, died on the 24th day of April, 
1862, with the following history ' It was wet-nursed, fleshy, and appar- 
ently well, till six days before death, when symptoms of gastro-intestinal 
inflammation were suddenly developed. The vomiting, especially, was 
severe, continuing forty-eight hours. When it ceased, drowsiness super- 
vened, and continued till the close of life. The face during the four days 
of stupor was pallid and cool ; eyes partly open, pupils sluggish, but of 
equal size ; bowels rather torpid ; anterior fontanelle depressed. When 
aroused, the infant noticed objects for a moment, and immediately relapsed 
into sleep ; pulse accelerated and not intermittent, the day before death 
numbering one hundred and fifty ; respiration accelerated, without sigh- 
ing, numbering on the same day thirty. There were no convulsions, and 
death occurred quietly. The brain weighed twenty and a half ounces, 
and its appearance was perfectly heathy, both as regards consistence and 
vascularity. The amount of cerebro-spinal fluid in the ventricles and at 
the base of the brain was not notably increased. The stomach, small and 
large intestines, were vascular in streaks and patches. 

In this case the cerebral symptoms were obviously 4 due to exhaustion 
occurring at an early period, in consequence of the severity of the gas- 
tro-intestinal malady. 

In a majority of cases, however, of spurious hydrocephalus, according 
to my observation, there is an anatomical alteration in the state of the 
brain and meninges. This consists in passive congestion of the veins, 
often with transudation of serum. At the same time the cranial sinuses 
are congested, and are found at the post-mortem examination to contain 
larger and more numerous clots than are present in those who die of 
diseases which do not affect the encephalon. Cases might be cited as 
examples. The cause of this congestion and effusion is, in great measure, 
feebleness of the circulation due to the general exhaustion of the patient. 
But there is another cause. In protracted diseases, especially those of 
a diarrhoeal character, there is more or less wasting of the brain as well 
as of other parts. This naturally, by way of compensation, gives rise 
to congestion of the cerebral and meningeal veins and capillaries and to 
transudation of serum. 

The transudation commonly occurs in this malady over the superior 
surface of the brain and in the subarachnoidal space, perhaps also more 
or less in the lateral ventricles. So common is it in the last stage of 
infantile entero-colitis, the summer epidemic of cities, that this stage, 
which is really spurious hydrocephalus, has been called the stage of 
eifusion. I shall relate in another place examples which show the 
anatomical characters of this intestinal disease. 

Symptoms. — Spurious hydrocephalus most frequently results from 
protracted diarrhoeal complaints. It may, however, result from any 



472 SPURIOUS HYDROCEPHALUS. 

disease which is attended by great prostration. As it ordinarily occurs, 
the patient has for days or weeks been gradually losing flesh and 
strength. Finally, drowsiness supervenes, or before the drowsiness 
there is sometimes a period of irritability. 

Marshall Hall describes two stages of spurious hydrocephalus. In the 
first he says : " The infant becomes irritable, restless, and feverish ; the 
face flushed, the surface hot, and the pulse frequent ; there is an undue 
sensitiveness of the nerves of feeling, and the little patient starts on 
being touched, or from any sudden noise ; there are sighing and moan- 
ing during sleep, and screaming ; the bowels are flatulent and loose, 
and the evacuations are mucous and disordered." The second stage he 
describes as that of torpor. The first stage often, however, does not 
present those prominent symptoms which have been described by Dr. 
Hall, and this stage may even be absent, or not appreciable, especially 
in young infants. 

Whether or not commencing with the stage of irritability, the dis- 
ease, if not checked, gradually increases. The child soon becomes 
drowsy. He may be aroused for a moment, but, unless constantly dis- 
turbed, immediately relapses into sleep. He is sometimes fretful when 
aroused, but in other instances is quite indifferent, observing without 
apparent interest objects employed for the purpose of amusing him. 
Often there are indications of cerebral pain or distress, as contraction of 
the eyebrows, etc., but many of those affected are too young to make 
known their sensations. Convulsions sometimes occur toward the close 
of life, but they are not so common in this disease as in meningitis. 
When they do occur, they are generally partial and often slight. The 
pulse is accelerated in most patients prior to and in the commencement 
of spurious hydrocephalus. As the disease advances it becomes irregu- 
lar and intermittent, and toward the close of life it is progressively more 
frequent and feeble. The respiration at first is not much disturbed, but 
at length it becomes irregular, like the pulse. It is feeble and accompa- 
nied by sighs. Occasionally there is slight cough. The eyelids are 
partly open, the pupils no longer respond to light, and in advanced 
cases they have a bleared appearance. The diarrhoea, which in most 
instances precedes and causes this malady, continues till the stage of 
stupor arrives, when the evacuations become less frequent or cease alto- 
gether. In infants the stools are frequently green, in older children 
brown and sometimes slimy. The febrile heat of surface which pre- 
ceded the disease, and which was present in its commencement, disap- 
pears ; the face and hands become cool, the features pallid, and the 
anterior fontanelle, if open, is depressed. Death finally occurs in a 
state of coma, or if the disease be recognized and proper remedial meas- 
ures employed, the result may be favorable, even when the symptoms 
are such that if meningeal inflammation were the malady we would 
consider the case necessarily fatal. 

The following case is an example of spurious meningitis as we often 
meet it in practice : 

Case. — On the 13th day of March, 1859, I was asked to see a male 
child twenty -two months old, the records of whose case are as follows : 
" Was well till about three weeks ago, since which time he has had 



SYMPTOMS. 473 

diarrhoea, with febrile symptoms; pulse 162, respiration 52; has a slight 
cough, with a few mucous rales ; resonance on percussion of chest good ; 
is somewhat emaciated, and appears languid ; tongue moist and slightly 
furred. Has all the incisor and three anterior molar teeth, and the gum 
is swollen over the remaining anterior molar and two canine teeth." 

" From the 14th to the 18th there was no material alteration in his 
symptoms, with the exception that the diarrhoea was partially restrained 
by Dover's powder in one and a half grain doses. On these five days the 
stools numbered daily from one to six. The pulse was uniformly frequent, 
varying from 124 to 156, and the respiration on two days, when its fre- 
quency was ascertained, numbered 56 and 46. 

"March 19th, pulse 124; has become drowsy since yesterday, and when 
aroused is fretful. Omit Dover's powder. Treatment, cold applications 
to the head, mustard pediluvia. 

"Evening, pulse 136; eyes constantly closed and head reclining; sur- 
face generally warm ; tongue dry and furred ; he vomited at first, but has 
not in three or four days. Apply cantharidal collodion behind each ear, 
and continue the local treatment. 

" 20th, pulse 130 ; is constantly sleeping, and when aroused is very fret- 
ful and soon relapses into sleep ; no unnatural heat of head, and no dejec- 
tion since yesterday. Treatment, a dose of castor oil, nourishing diet. 

" 21st, drowsiness as before ; cheeks sometimes flushed, sometimes pallid ; 
pupils sensitive to light ; margins of eyelids covered with secretion. The 
Dowels have been opened by the oil." 

On the 22d and 23d there w T as no material change in the symptoms. 
He was constantly sleeping, except for a moment when shaken. More 
active stimulation was now employed. Brandy was prescribed, to be given 
every two hours ; beef tea and milk porridge frequently. 

On the following day, the 24th, he was more fretful, and less drowsy. 
Brandy and beef tea were continued. 

On the 25th, with the same treatment, there was still further improve- 
ment ; drowsiness nearly gone and less fretfulness than yesterday ; rolls 
the head occasionally and does not appear to see distinctly ; has a slight 
cough; stools nearly regular; pulse 100; respiration natural; surface 
warm, and no unnatural heat of head. The same treatment was con- 
tinued, and he rapidly and fully recovered. 

This case is interesting on account of the long duration of marked 
drowsiness, which continued five days, and yet the patient recovered 
entirely in the space of two or three days under the use of brandy and 
beef-tea. 

In May, 1860, I was called to treat a very similar case. A child, 
twenty months old, had diarrhoea for two weeks, the stools being of a 
dark-brown color, thin and offensive. He was at first very irritable. 
The pulse was constantly above 130, and the respiration was corre- 
spondingly increased. The stage of drowsiness finally supervened, and 
for two days he was constantly asleep unless aroused by being shaken. 
During the somnolent stage the pulse numbered 140, respiration 36. 
The face and extremities were cool, and he finally had a slight convul- 
sion. By stimulants and nutritious diet he began immediately to 
improve, and was soon out of danger. 

In the following case the result was unfavorable. This case is inter- 
esting on account of the anatomical characters of the disease as disclosed 



474 SPURIOUS HYDROCEPHALUS. 

by the post-mortem examination. It is an example of that large class 
of cases in which spurious hydrocephalus is associated with congestion 
of the cerebral vessels and serous effusion. It is exceptional, however, 
as regards the long duration of drowsiness. Ordinarily, protracted 
diarrhceal maladies which end in passive congestion and effusion termi- 
nate fatally in three or four days after the drowsy period arrives. 

Case. — "Dec. 13, 1861, called to-day to a German infant eighteen 
months old. It has had diarhoea four weeks without regular and proper 
medical attendance ; stools from the first brown and thin ; during the last 
eight or nine days he has been drowsy ; when aroused, opens his eyes and 
is very fretful, but immediately the upper eyelids gradually droop, and, 
unless disturbed, he remains asleep with his eyes partially open ; forehead 
warm, face cool and pallid, and limbs also rather cool ; pulse 164, respira- 
tion 32 ; has had a slight cough about one week, and slight dulness on 
percussion over the left infra-scapular region ; depression of infra-mam- 
mary region on inspiration. Treatment : Ammon. carbonat., gr. 1 every 
two hours ; nourishing diet. 

" Dec. 20th, has continued drowsy since the last record ; pupils mod- 
erately dilated ; a thick secretion between eyelids ; right pupil considerably 
larger than the left ; vision apparently lost during the last three days ; 
pulse over 140 ; respiration 44 per minute, accompanied by sighing since 
the 18th; moans much when awake; rolls the head frequently; during 
the last six days the surface back of the ears has been constantly sore by 
vesication ; takes the most nutritious diet, with brandy. The dejections 
remain thin and brown, and number three or four daily. 

" From this date the diarrhoea continued, except as it was restrained by 
vegetable astringents. The pulse continued frequent, and a slight cough 
remained. There was on the 21st and 22d partial abatement of the 
drowsiness, but on the 23d it was greater than ever. The body w T as some- 
what reduced at the commencement of the cerebral symptoms, but it was 
now considerably emaciated. The prostration increased daily, and the 
hands w T ere observed to tremble. The face and hands became more cool, 
while the head was warm. On the 24th partial convulsions occurred, 
followed by coma and death. 

" The cerebral veins and sinuses were generally congested, except in 
the anterior portion of the brain, where the appearance was normal. Be- 
tween the brain and its membranous covering, chiefly at the vertex and 
the base, was an effusion of clear serum. The whole^ amount of this fluid 
was estimated at two ounces. On slicing the brain, numerous ' puncta 
vasculosa ' were seen, both in the gray and white portions. With the ex- 
ception of the congestion, the substance of the brain presented its normal 
appearance. No inflammatory lesions were present. We were not per- 
mitted to examine the condition of the intestines." 

Diagnosis. — The only disease with which spurious hydrocephalus is 
liable to be confounded is meningitis. The points of differential diag- 
nosis are the history of the case, especially the antecedent diarrhoea or 
other exhausting ailment, evidence of prostration when the cerebral 
malady commenced, depression of the anterior fontanelle if it be open, 
and the cool face and extremities. 

Prognosis. — If the pathological state of the brain be simple exhaus- 
tion, the disease can often be arrested by judicious treatment. If an 



TREATMENT. 475 

incorrect diagnosis be made, and the treatment employed be that appro- 
priate for meningitis, which it so closely simulates, death is almost 
inevitable. If transudation of serum have occurred, unless slight, the 
result is usually unfavorable, whatever may be the treatment. This 
disease in childhood is more easily managed than in infancy, but is less 
frequent. The prognosis is better in the cool months than during the 
heat of summer. It is more favorable if the child be over than if under 
the age of one year. The occurrence of an irregular and intermittent 
pulse, of respiration accompanied by sighs, of inequality in the pupils, 
or their sluggish movements, with increasing stupor, indicates an unfa- 
vorable issue. The cure of the primary disease, with the pulse and 
respiration still natural, or accelerated, without change of rhythm, 
pupils sensitive to light, drowsiness from which the patient is easily 
aroused to a state of entire consciousness, render recovery probable, 
with proper medication and alimentation. 

Treatment. — The indications of treatment are twofold : first, to 
remove the primary pathological state which is the cause of the spu- 
rious hydrocephalus; and, secondly, to cure the latter. The first is 
important, since the successful treatment of a disease requires the 
removal of the cause. The measures employed for this purpose are 
pointed out in our description of the diarrhoea! and other maladies which 
produce spurious hydrocephalus. 

We may here say that as spurious hydrocephalus is due in a very 
large proportion of cases to the exhausting effect of long-continued diar- 
rhoea, astringents, especially subnitrate of bismuth, and alkalies are 
required in a majority of cases in the stage of irritability, and sometimes 
also opiates. 

Active sustaining measures are indicated. Exhausted nervous power, 
as well as passive cerebral congestion, requires this. The diet should 
be highly nutritious, comprising such substances as milk and beef-juice, 
and should be given frequently. Brandy is required at short intervals. 
Dr. Gooch was in the habit of giving the aromatic spirits of ammonia, 
properly diluted, as a quick and active stimulant. Six or eight drops 
may be given in sweetened water to a child one year old, and repeated 
every hour in cases of urgency. If, by proper treatment of the cause, 
and by the use of stimulants and nutritious food, the patients do not 
within a few hours become less stupid and more conscious, there is that 
degree of nervous exhaustion or of serous transudation from the engorged 
cerebral veins, which will render death probable. In some cases it is 
proper to produce moderate vesication behind the ears. 



476 ECLAMPSIA 



CHAPTEE XI. 

ECLAMPSIA. 

The term eclampsia is used in a more restricted sense by some 
writers than by others. It is employed in the following pages to desig- 
nate those convulsive seizures, clonic in their character, sometimes 
general, sometimes partial, which affect the external muscles. Eclampsia 
is therefore synonymous with clonic convulsions. It consists in rapid, 
forcible, and involuntary muscular contraction, alternating with relaxa- 
tion. It is distinguished from chorea in the fact that the latter is a 
more permanent state, and is characterized by muscular movements 
which are partially under the control of the will, and are not so violent. 

Eclampsia occurs in a great variety of diseases, some of which are 
located in the cerebro-spinal system, some in other parts of the body, 
and some are constitutional. It may also be produced by temporary 
derangements of system not sufficiently severe to be considered dis- 
eases, and by powerful mental impressions, those of an emotional nature, 
affecting the delicate and sensitive nervous system of the child. Pa- 
thologists recognize three different forms of eclampsia. The term 
essential or idiopathic is used when the convulsions have no appreciable 
anatomical character, that is, when there is no apparent pathological 
state in the brain or elsewhere, which gives rise to the attack. For 
example, if a child die in convulsions from fright, and all the organs, 
including the brain, are found in their normal state, the eclampsia is 
called idiopathic or essential. If the cause be disease of the brain or 
spinal cord, it is termed symptomatic. If eclampsia arise from local 
disease elsewhere than in the cerebro-spinal axis, as from pneumonia, 
the term sympathetic is employed. This is in the main a good division, 
but eclampsia may be at the same time sympathetic and symptomatic, 
as when it occurs in consequence of congestion of brain, which is induced 
by severe and frequent paroxysms of hooping-cough* 

Causes. — Eclampsia occurs at any period of infancy and childhood, 
but it is much more rare after the period of six or seven years than 
previously. Some children are more liable to it than others. It is 
produced in one by an agency which in another has no appreciable 
effect. Thore are some, generally those of an impressible nervous 
system, who are seized with convulsions whenever there is any slight 
derangement in the digestive or other organs. Eclampsia is frequent 
in certain families. Thus, Bouchut mentions a family of ten persons, 
all of whom had convulsions in their infancy. One of them married, 
and had ten children, all which, with one exception, had convulsions. 

The exciting causes of eclampsia are too numerous to be mentioned 
in full. It is a symptom in nearly all cerebral diseases. • It is produced 
in the nursling by changes in the milk with which it is nourished. 



PREMONITORY STAGE. 477 

These changes are usually due to violent emotions of the mother, as 
anger, fright, and grief, to the use of acescent or indigestible food, or 
to derangement, temporary or permanent, in her health. Thus, in a 
case related to me, the catamenia so affected the milk that the infant 
was seized with eclampsia at each monthly period. In childhood the 
most common cause of clonic convulsions is the presence of some irri- 
tant in the primae vine. All kinds of fruit, even the mildest, may pro- 
duce eclampsia, especially when eaten unripe or taken in undue quan- 
tity. I have known an infant to be seized with convulsions from eating 
strawberries, which parents usually regard as harmless, and one of the 
most violent and protracted cases of eclampsia which I have witnessed, 
occurred in a child over the age of six years, from swallowing, in con- 
siderable quantity, the parenchymatous portion of an orange. Consti- 
pation, worms, dysentery, intussusception, and painful dentition are also 
causes which are located in the digestive apparatus. Inflammation in 
some part of the respiratory apparatus is a not infrequent cause. 
Thus eclampsia occurs occasionally in severe coryza, in consequence, 
according to some, of the proximity of the inflamed surface to the brain, 
and the consequent afflux of blood to this organ. It is a common com- 
plication also of pertussis and pneumonia. It occurs often at the com- 
mencement of two of the eruptive fevers, namely, smallpox and scarlet 
fever, and in the course of the latter disease. 

Violent emotions of the child may also cause eclampsia. Bouchut 
relates the case of a girl, five years old, who was corrected before her 
companions, and was so aifected by anger that convulsions ensued. 
Residence in close and overheated apartments, or in streets where the 
air is loaded with offensive vapors and is stifling, is a predisposing 
cause, so that there is a larger proportion of deaths from convulsions in 
the cities than in the country. 

In young children, burns, even when not very severe, are liable to ter- 
minate suddenly in eclampsia, succeeded by coma and death. Urinary 
calculi, both renal and vesical, frequently produce the same result. 

Such are the more common causes of eclampsia. It is seen that 
they are of two kinds, predisposing and exciting. An excitable or 
impressible state of the nervous system constitutes the chief predispo- 
sition to the disease. Plethora, or its opposite state, anaemia, increases 
the liability to an attack. 

Premonitory Stage. — In the majority of cases there are prodromic 
symptoms, which the experienced and careful physician can detect, so 
as to forewarn friends. The child is perhaps more or less drowsy, and, 
when disturbed, fretful. The eyes often have a wild or unnatural 
appearance ; occasionally they are fixed for a moment on an object, and 
yet apparently without noticing it. The sleep is disturbed ; in some 
there is unusual heat of head, and, if old enough, complaint of head- 
ache. At times, especially if the primary disease be febrile or inflam- 
matory, there is incoherence of thought or expression, or even actual 
delirium. In some children, when eclampsia is threatening, the thumbs 
are seen to be carried across the palms. I have observed this especially 
during the convulsive cough of pertussis. A very important prognostic 
symptom is sudden starting, or twitching of the limbs. This shows 



478 ECLAMPSIA. 

that the nervous system is profoundly impressed, and but slight addi- 
tional excitation is required to develop eclampsia. This sudden starting 
not infrequently precedes the attack several hours, and gives sufficient 
forewarning. 

The prodromic symptoms are often disregarded by friends who do not 
understand their significance. Even physicians, in the haste of their 
visits, in many instances do not notice them. The symptoms which 
precede symptomatic and sympathetic eclampsia, are, moreover, blended 
with those of the primary affection, and hence another reason why they are 
frequently overlooked. When the convulsions are about to commence,, 
the child generally lies quiet ; the eyes are open and fixed. If spoken 
to or shaken, he takes no notice, and does not speak. The direction of 
the eyes is then changed ; often they are turned up ; occasionally there is 
strabismus. The face may be pale or flushed, and sometimes, especially 
in cerebral diseases, the features present patches or streaks of a flushed 
appearance, while around them the natural color is preserved. Imme- 
diately before the spasmodic movements the child sometimes utters a 
piercing scream, which is probably involuntary, though it seems like a 
supplication for help. The duration of the prodromic stage is very dif- 
ferent in different cases. It may last from a few minutes to several 
hours, or even more than a day. 

Symptoms. — Eclampsia is general or partial. If general, the muscles 
of the face, eyes, eyelids, and of all the limbs, are in a state of rapid in- 
voluntary contraction, alternating with relaxation. The features lose 
their natural expression and are distorted ; the mouth is drawn out of 
shape, often to one side, by the violent muscular action ; the teeth are 
pressed together by tonic contraction of the masseters, and may be vio- 
lently struck together, so as to lacerate the tongue, if it protrude, or are 
ground upon each other. Unless the attack be of short duration, frothy 
saliva, perhaps tinged with blood from the injured tongue, collects be- 
tween the lips. The eyelids are usually open, and in severe cases the- 
eyes are turned so that the pupils are lost under the upper eyelids, or 
the muscles of the eyes are involved in the spasmodic movements, so 
that the eyeballs are forcibly drawn from side to side. Occasionally 
strabismus occurs. While the features are thus distorted, the head is 
strongly retracted or is turned to one side ; the forearms are alternately 
pronated and supinated ; the thumbs and fingers are .convulsively flexed, 
so that the thumbs lie across the palms and are covered by the fingers ; 
the great toe is adducted, the other toes flexed ; and the toes, as well as 
legs, participate more or less in the spasmodic movements. 

In general convulsions, consciousness is usually lost. The head is 
hot previously to and during the attack — at least in the first part of it — 
and the face flushed. In exceptional cases, especially in sympathetic 
eclampsia, the head is cool and the face pallid. The pulse is somewhat 
accelerated, as well as the respiration, and the latter is rendered irreg- 
ular if the respiratory muscles, especially those of the larynx, are in- 
volved, as they generally are. The sphincters are relaxed during the 
convulsive attack, so that in many cases the urine and stools are passed, 
involuntarily. 



PREMONITORY STAGE. 479 

Partial eclampsia is more common than the general form ; it occurs 
in the muscles of the face, including those of the eye, of the face and of 
one or both upper extremities, or of the face and the extremities on one 
side. The spasmodic movements may be even limited to the muscles of 
the eye, and they often occur only in these muscles and those of the face. 
Rarely, if ever, does eclampsia affect the legs without affecting also the 
muscles of the arms and face. In partial convulsive attacks, sensation 
and consciousness are in some patients not entirely lost, but in others 
they are not manifested if present. 

The duration of an attack of eclampsia varies in different cases from a 
few minutes to several hours, with an average of not more than from 
five to fifteen minutes. The movements do not often continue longer 
than three or four hours in the severest cases. They are sometimes 
said to last a much longer time, even for days, but in these cases there 
are intermissions. Violent attacks are usually short. 

When the convulsion ends favorably, the spasmodic movements become 
less and less strong, and finally cease. The child then takes a deep in- 
spiration, after which it lies quiet, and the respiration remains regular 
or moderately accelerated. Some fully recover in a few minutes if the 
eclampsia have been light and the cause transient, and seem to experi- 
ence no inconvenience except soreness of the muscles and fatigue. 
Others soon recover consciousness, and their temperature, respiration, 
and circulation become natural, but they remain dull for a time, their 
minds are bewildered, and they are perhaps unable to speak. In a few 
hours these untoward symptoms pass away. In essential, and in a large 
proportion of cases of sympathetic eclampsia, if properly treated, and if 
the cause be recognized and removed, there is no recurrence of the con- 
vulsion ; with others it is different. In many cases, especially of symp- 
tomatic eclampsia and of sympathetic, in which the cause is grave and 
persistent, the convulsions return after a variable period of a few minutes 
or a few hours. Six or eight or more convulsions may occur within 
twenty-four hours. Rarely they occur several times daily for several 
consecutive days, but severe convulsions, repeated at short intervals for 
twenty-four or forty-eight hours, usually end in fatal congestion of the 
brain or serous effusion. I once attended an infant about six months 
old, who had from four to twelve convulsions daily for eleven days, 
caused probably by a vesical calculus, as there was dysuria, and, at 
times, bloody urine. Some days after the convulsions were controlled, 
while we were deferring exploration of the bladder, death occurred sud- 
denly, and an autopsy was not permitted. This case will be detailed 
elsewhere. Bouchut has witnessed a case of hooping-cough in which 
there were daily convulsions for eighteen days. 

In severe eclampsia, the respiration is so embarrassed and circulation 
so retarded that congestion of various organs results. This passive con- 
gestion in the respiratory organs is indicated by moist rales in the larynx 
and bronchial tubes ; occurring in the brain, it is indicated by profound 
stupor. It has already been stated that death may occur from the 
cerebral congestion, which, continuing, is apt to end in effusion of 
serum or extravasation of blood. In these cases the convulsive move- 
ments cease, but there is no return of consciousness. The child lies 



480 ECLAMPSIA. 

quiet, as if in sleep, with pupils not readily acted on by light, and often 
somewhat dilated ; gradually the limbs grow cool and the pulse feeble, 
and fatal coma supervenes. 

Death does not ordinarily occur from one attack. There are several 
at intervals, during which the stupor is gradually becoming more and 
more profound, till, finally, total loss of consciousness and sensation 
results, terminating in death. Apnoea may occur in the first attack, 
ending life abruptly and unexpectedly, but in other instances it does not 
result till after several seizures, when, at length, one more violent than 
the others interrupts the respiratory function and causes death. 

Occasionally, when life is preserved, there is some permanent ill-effect 
of eclampsia. Bouchutsays: " The origin of certain permanent con- 
tractions which bring on deviation of the head or of other parts, retrac- 
tion of the limb, paralysis, etc., must be referred to the convulsions of 
the muscles. I have seen several children in whom torticollis had no 
other cause. The drooping of the upper eyelid, strabismus, irregularity 
of the mouth, severe contractions of the limbs, often depend on this 
influence. These accidents are consequences of essential as well as of 
symptomatic convulsions." 

Anatomical Characters. — The morbid anatomy pertaining to 
eclampsia is in most cases twofold : first, the pathological states which 
precede and cause the convulsive movements; secondly, those which 
result from them. We have seen that in sympathetic eclampsia the dis- 
eases which sustain a causative relation are very numerous; some are 
constitutional, others local, and the latter may have their seat in almost 
any part of the economy, distinct from the cerebro-spinal axis. In 
some cases of sympathetic eclampsia the immediate cause is too active a 
circulation, a state of hyperemia of the cerebral vessels. 

It has already been stated that this hyperemia may be diagnosticated 
in young infants in whom the anterior fontanelle is open. Such infants, 
seized with acute inflammation of the mucous surfaces or of the lungs, 
often present a full and rapid pulse and a convex and forcibly pulsating 
fontanelle before the eclampsia begins. In other cases of sympathetic 
eclampsia the primary disease induces passive congestion of the brain, 
and this in turn gives rise to convulsions. Eclampsia occurring during 
the paroxysms of hooping-cough affords an example. In the contagious 
diseases, as smallpox and scarlet fever, eclampsia is doubtless often 
produced by the direct action of the specific virus on the cerebro-spinal 
system. Therefore, in a considerable proportion of cases of eclampsia 
due to diseases not located in the cerebro-spinal system — in other 
words, of sympathetic eclampsia — the primary disease induces a patho- 
logical state of the cerebral vessels, or of the blood which circulates 
through them, which state immediately precedes and accompanies the 
convulsions. 

In other cases of sympathetic eclampsia the convulsive movements 
are produced by the primary disease acting directly on the nervous 
system, through the medium of the nerves, without causing any appre- 
ciable alteration in the state of the cerebro-spinal axis. Thus Barrier 
relates three fatal cases of convulsions occurring in pneumonia, in none 



DIAGNOSIS. 481 

of which was there anything abnormal in the condition of the brain or 
its membranes. 

The pathological state preceding symptomatic eclampsia differs in 
different cases, since convulsions occur in almost every disease of the 
brain and its membranes. The immediate cause of this form of 
eclampsia may be active or passive cerebral congestion, with or with- 
out effusion ; it may be compression of the brain from various causes ; 
it may be a deficiency as well as excess of the cerebro-spinal fluid. 

In essential eclampsia the cause sometimes produces congestion of 
the brain prior to the convulsive seizure. In other cases, as when con- 
vulsions occur immediately from the effect of anger or fright, there is 
no appreciable change in the state of the nervous centres previously to 
the attack. 

Again, eclampsia, especially when severe and protracted, and when 
occurring in successive attacks, may be the cause of certain lesions. 
It produces congestion of the brain and membranes, and perhaps of 
the spinal cord. Sometimes if the congestion be great, there is also 
escape of serum from the distended capillaries, and the fibrin in the 
larger vessels, as the sinuses, may coagulate. 

Ths congestion resulting from eclampsia may give rise to extravasa- 
tion of blood and the formation of a clot. If this accident occur, there 
is often paralysis affecting more or less of one side, permanently or 
gradually disappearing. 

It may be difficult to decide whether the cerebral congestion precedes 
the eclampsia or is its result ; but in 4:hose cases in which it precedes 
and operates as a cause, it is no doubt increased during the convulsive 
period. The spasmodic muscular action, by rendering respiration 
irregular and imperfect, also leads to congestion of the lungs and some- 
times of the abdominal organs. 

Diagnosis. — The only disease for which there is danger of mis- 
taking eclampsia is epilepsy, but the diagnosis can ordinarily be made 
by recollecting the following facts : Eclampsia is most common in 
infancy. If it occur after the age of three years there is some manifest 
exciting cause, which renders the child seriously sick independently of 
the convulsions, and prior also to their occurrence. Eclampsia very 
seldom occurs in one who has reached the age of three years, even with 
a strong predisposing cause, unless he have been subject to it during 
the period of infancy, as shown by his history. On the other hand, epi- 
lepsy rarely occurs before the age of three years. The first attacks of 
it are very often mild, the petit mat of writers, but in other cases they 
are tolerably severe from the first, but whether mild or severe, they 
occur with no previous or coexisting sickness, and with little or no 
warning. 

Having seen a considerable number of epileptic children in the 
Bureau for the Relief of the Outdoor Poor during the last ten years, I 
have been surprised to learn how few had eclampsia when infants. It 
was exceptionally the case that a child having epileptic attacks com- 
mencing as ordinarily they did, between the third and tenth years, gave 
the history of infantile eclampsia, and yet the convulsive movements in 
the two diseases seem to be identical. I cannot agree with some that 

31 



482 ECLAMPSIA. 

the phenomena in eclampsia and epilepsy differ, except as the causes of 
eclampsia produce certain concomitant symptoms, and there is every 
reason to believe that the spasmodic muscular movements proceed from 
an irritation of the same portion of the cerebro-spinal axis, to wit, the 
medulla oblongata. Writers like Niemeyer have given reasons for the 
belief that spasmodic muscular movements are produced by functional 
disturbance of this part of the nervous centre. I may state the follow- 
ing, to which I am not aware that any one has alluded. If the exposed 
medulla of an acephalous monster be pressed or pinched, convulsions like 
those of eclampsia and epilepsy result. These two diseases, therefore, 
have a close resemblance anatomically and clinically, but by attention to 
the above facts they can ordinarily be distinguished from each other. 

It is often difficult to ascertain the form of eclampsia, whether essen- 
tial, symptomatic, or sympathetic — in other words, to determine the 
cause — till after the convulsions cease. This is especially true when, as 
is frequently the case, the physician is not summoned till the convulsive 
movements begin, and it is necessary that he should act promptly, with 
but little knowledge of the child's previous history. If there be an 
obvious antecedent disease, as hooping-cough or meningitis, the cause is 
apparent ; but if the previous health have been good, or but slightly dis- 
turbed, it may be necessary to make more than one visit or examination 
in order to ascertain the seat and character of the cause. In the ma- 
jority of cases of convulsions occurring suddenly in a state of previous 
good health, the cause is seated in the intestines, but sudden and unex- 
pected attacks may be due to the commencement of some inflammatory 
affection, as pneumonia, or of a febrile disease, as smallpox. Unless the 
eclampsia be speedily fatal, the physician, if he examine carefully, will, 
in most cases, soon be able to ascertain the nature of the cause, and 
diagnosticate the form of the disease. 

Prognosis. — Symptomatic eclampsia is always serious. If it occur 
in the course of a cerebral disease, it indicates the approach of death, 
but if at the commencement, some may recover. Its recurrence, what- 
ever the cerebral disease, is an almost certain prognostic of death. 

In idiopathic or essential convulsions the prognosis depends on the 
severity of the attack, and on the age, strength, and previous condition 
of the child. If there be predisposing or cooperating causes, as a nervous 
or excitable temperament, or dentition, the prognosis is less favorable 
than when such causes are absent. 

In sympathetic eclampsia the prognosis varies greatly, according to 
the nature of the primary disease, and often according to the stage of 
that disease. If convulsions occur at the commencement of an eruptive 
fever, they generally subside without untoward symptoms, and the fever 
pursues a favorable course. Eclampsia, after the appearance of the 
eruption, is premonitory of a fatal result. I have not yet known a 
patient with scarlet fever recover who had convulsions after the rash 
had covered the body, and experienced physicians of this city tell me 
that their observations correspond with mine. Dr. J. F. Meigs, how- 
ever, relates one favorable case. If the cause of the eclampsia be 
located in or upon the mucous surfaces, a majority recover with judi- 



TREATMENT. 483 

cious treatment. In convulsions consequent on pneumonia or a burn, 
more die than recover. 

The prognosis in eclampsia is more favorable if the parallelism of the 
eyes be retained, the pupils remain sensitive to light, and consciousness 
soon return. A fatal termination may be predicted, if, after the convul- 
sion, the child remain stupid, without any evidence of returning con- 
sciousness, and the pupils do not respond to light. 

Treatment. — Fortunately, inasmuch as the physician is often re- 
quired to treat eclampsia in ignorance of the cause, the same measures 
are demanded, to a considerable extent, in all cases, whether the form 
be essential, symptomatic, or sympathetic. As early as possible in the 
attack the feet should be placed in hot water to which mustard is added, 
or, if it can be procured with little delay, a general warm bath may be 
used in its place. This has a soothing effect upon the nervous system and 
promotes muscular relaxation, while it also produces derivation of blood 
from the cerebro-spinal axis. It is, therefore, useful, especially in those 
cases in which active or passive congestion precedes the eclampsia ; it is 
also useful as a preventive of passive congestion and consequent oedema 
of the brain, lungs, and other organs, which are the most serious results 
of eclampsia. It should be continued from six to fifteen or twenty 
minutes, according to the severity and duration of the attack ; at the 
same time cold applications should be made to the head, until its tem- 
perature, which is usually increased, is reduced. The application of 
cloths placed upon ice or frequently wrung out of cold water, is the 
most convenient and ready mode of employing this agent. Cold thus 
employed acts promptly in contracting the vessels of the brain and 
meninges, and diminishing the cerebral congestion. It tends, therefore, 
to remove one of the chief dangers. 

Cold applications are also useful for reducing an elevated temperature, 
if it be present. In most cases of eclampsia, if the temperature reach 
103°, the necessity for its reduction is urgent, and the cloths or India- 
rubber bag containing ice should be applied not only upon the head, 
but also along the sides of the face, and sometimes over the great vessels 
of the neck. 

As a large proportion of convulsive attacks originate in the condition 
of the intestines, either solely or in part, it is advisable to prescribe an 
aperient unless there be previous diarrhoea. 

The common enema of soap and water will usually produce a free and 
speedy evacuation, and will sometimes disclose the cause of the eclampsia 
in the expulsion of seeds or other indigestible substances or scybala. A 
cathartic is also often required, especially if the enema fail to produce 
sufficient evacuations. In those that are robust, and especially in those 
beyond the age of two or three years, calomel is an excellent purgative, 
is easily given, and is prompt in its action. If the symptoms indicate 
intestinal inflammation, the milder purgatives, as castor oil, are prefera- 
ble, as they also are in young or feeble children. If the recent ingesta 
of the patient consisted of fruit or of substances of an indigestible char- 
acter, an emetic is appropriate ; a teaspoonful of the syrup of ipecac- 
uanha, repeated if necessary in fifteen or twenty minutes, may be given 
to a young child, or this syrup mixed with the syrup, scillse compositus 



±84: ECLAMPSIA. 

to one older and more robust. Aside from the ejection of the offend- 
ing substance which it produces, an emetic has some effect in con- 
trolling the convulsive movements. But the cases are rare in which 
emetics are indicated. 

In addition to the local measures mentioned above, and measures cal- 
culated to relieve the digestive canal of any offending substance, a safe 
medicinal agent which will act promptly in relieving the convulsions is 
urgently demanded, since eclampsia, if severe and protracted, involves 
great danger. Fortunately such agents have been lately introduced into 
therapeutics, namely, the bromide of potassium or sodium, and hydrate 
of chloral. These agents, while they are effectual, are safe, and, there- 
fore, their use has supplanted that of the antispasmodics, asafoetida, 
valerian, lavender, and chloroform, formerly employed; not one of which, 
except chloroform, exerts any direct controlling influence over the con- 
vulsions, and chloroform is a dangerous remedy unless used sparingly. 

The bromide of potassium, which I prefer, should be given every ten 
minutes, dissolved in cold water, till the convulsions cease, in doses of 
three grains to a child of one year, and of four or five grains to a child 
of two or three years. When the convulsions cease, the interval between 
the doses should be lengthened. In one instance in my practice an 
infant of eighteen months was suddenly seized with eclampsia, and the 
mother in her fright mistaking the directions, gave thirty grains of 
bromide at one dose. Two hours afterward, when I was able to attend, 
I found that the convulsions had ceased at once, and that the patient 
was playful. Such cases show the innocuousness of a large dose of the 
bromide, and the safety in administering the medicinal dose often. 

In severe cases the bromide does not always act with sufficient prompt- 
ness and power. The hydrate of chloral should then be employed, 
given by the mouth or dissolved in two or three drachms of water, and 
given with a small glass or gutta-percha syringe per rectum. If used 
in sufficient quantity per rectum, and retained by pressure with a 
napkin, it is quickly absorbed, and will usually, in about fifteen or 
twenty minutes, control the movements. For a child of one year I 
employ about two grains, and for one of four years four grains, given 
by the mouth, or double this quantity given per rectum. With the 
use of the measures indicated above, eclampsia is, in my practice, 
much more amenable to treatment than in former years. Unless the 
cause be such that recovery is impossible from the very nature of the 
case, the convulsions will soon cease with these measures. It is inter- 
esting to observe the effect of the chloral enema. In from five to ten 
minutes the convulsive movements cease in the muscles of the face, a 
moment later in those of the arms, and lastly in those of the lower 
extremities. 

But additional treatment may be required, according to the path- 
ological state which has brought on the eclampsia. If it be an eruptive 
fever, as scarlatina, and the eruption have receded, active revulsive 
measures, as hot mustard baths, are required ; if in dysentery, or other 
internal inflammation, the flaxseed and mustard poultice should be ap- 
plied over the parts affected. 

In those dangerous cases in which symptoms of cerebral congestion 



TETANUS INFANTUM. ±$0 

continue after the eclampsia ceases, additional treatment is required. 
The child remains drowsy, does not speak, or apparently suffer in any 
way, and the pupils act less readily than in health. If this condition 
remain after the lapse of a few hours, there is probably serous effusion. 
All attacks of eclampsia, unless the mildest, are followed by a period 
of drowsiness, but the persistence of it, with symptoms which indicate 
hyperemia, with perhaps effusion within the cranium, calls for the em- 
ployment of additional measures. Vesication by cantharidal collodion 
should then be produced behind the ears, mild revulsives be applied to the 
extremities, the head kept cool, the bowels open, and, in certain cases, 
a diuretic like iodide of potassium may be advantageously employed. 
The utmost care should be enjoined in reference to the hygienic man- 
agement of those who are subject to eclampsia. The diet should be 
nutritious, but bland, and all causes of excitement be studiously avoided. 



CHAPTER XII. 

TETANUS INFANTUM. 

Tetanus or trismus is one of the most interesting diseases of in- 
fancy. It is first, in point of time, in the long catalogue of fatal mala- 
dies. It occurs suddenly and unexpectedly in the robust as well as 
feeble, almost certainly destroying life within a few hours under modes 
of treatment heretofore employed. It is more frequent in some locali- 
ties and conditions of life than in others. In New York it is more 
common than tetanus at any other age, or, indeed, in all other ages, 
since the mortuary statistics of this city exhibit a larger number of 
deaths from this disease in the first year of life than subsequently. 
Infantile tetanus occurs, with very few exceptions, in the newborn. 

Interesting and important as is tetanus infantum, it must be con- 
fessed that our knowledge of it is much more limited and imperfect than 
it should be, when we consider what great advancement has been made 
in pathological inquiries during the present century. Our information 
in reference to its causation, symptoms, and proper treatment is not 
much in advance of that of M. Dazille, or Dr. Joseph Clarke, who 
lived in the latter part of the last century. 

Did we better understand the pathology of diseases in the newborn, 
or could we more accurately ascertain the condition of organs at this 
age, doubtless we should occasionally consider those phenomena which 
we now designate as a disease per se, under the title tetanus, as symp- 
toms of some other affection. But as tetanic rigidity and spasms in 
the newborn occur so abruptly, masking all other symptoms, and ordi- 
narily ending in dea.th, without our knowing certainly whether or 
not there is any antecedent disease, it seems proper that we should 



4:86 TETANUS INFANTUM. 

recognize the state in which such muscular rigidity occurs with such a 
rapid result as an independent affection. This explanation is required 
from the fact that I have added to the accompanying table one case 
from Billard, which this observer relates under the head of spinal men- 
ingitis. In this case, an infant three days old was attacked with con- 
vulsions. " His limbs were rigid and violently bent ; the muscles of 
the face were in a continual state of contraction." On the following 
day " the convulsions continued ; the body remained rigid, 

and the vertebral column, which the weight of the trunk will cause to 
bend with the greatest ease in a young infant, remained straight and 
immovable whenever the child was raised." At the autopsy, in ad- 
dition to meningeal apoplexy, which is often present in those who die 
of tetanus infantum, a thick pellicular exudation was found upon the 
spinal arachnoid. There is, therefore, a strict accordance of the symp- 
toms and history of this case with those which other observers describe 
as examples of tetanus infantum ; moreover, as a satisfactory reason for 
including this case in our statistics, certain observers, as we shall see, 
have reported epidemics of tetanus in which meningitis was the principal 
lesion. 

Fatal Cases. 

Case 1. Male ; taken when three days old ; lived sixty hours. Labatt, 

Edin. Med. and Surg. Jour., April, 1819. 
" 2. Female ; taken when three days old ; lived forty hours. Ibid. 
" 3. Taken when five days old ; lived fifty hours. Ibid. 
" 4. Taken when three days old ; lived one day. Ibid. 
" 5. Male ; taken when two days old ; lived two days. Billard, 

Treatise on Diseases of Children, Stewart's trans., p. 477. 
" 6. Male ; taken when three days old ; lived two days. Romberg^. 
" 7. Male ; taken when six days old ; lived ninety-three hours. Dr. 

Imlach, Month. Jour, of Med. Sei., Aug. 1850. 
" 8. Female ; taken at five days ; lived four days. Caleb Woodworth, 

M.D., Boston Med. and Surg. Jour., Dec. 13, 1831. 
" 9. Negro ; taken at seven days ; lived twenty-four hours. P. C. 

Gaillard, M.D., South. Jour, of Med. and' Phar., Sept. 1846. 
" 10. Male ; taken when seven days old ; lived one day. Augustus 

Eberle, M.D., Missouri Med. and Surg. Jour., 1847. 
" 11. Taken when seven days old. D. B. Nailer, N. 0. Med. Jour., 

Nov. 1846. 
" 12. Male ; taken when three days old ; lived one day. N. 0. Med. 

and Surg. Jour., May, 1853. 
" 13. Negro ; taken when three days old ; lived three days. Robert 

H. Chinn, M.D., N. 0. Med. and Surg. Jour. 
" 14. Taken when two days old ; died in four hours after the doctor's 

visit. Ibid. 
" 15. Taken when seven clays old; lived one day. C. H. Cleaveland, 

New Jersey Med. Bej)., April, 1852. 
" 16. Negro ; taken when seven days old ; death finally. Greenville 

Dowell, Amer. Jour, of Med. and Sei., Jan. 1863. 
" 17. Taken when twelve days old; lived one day, Thomas C. Bos- 
well, communicated to Dr. Sims, Amer. Jour, of Med. Sei., 

1846. 



PEKIOD OF COMMENCEMENT. 487 

Case 18. Taken when about five days old ; died at about the age of nine 
days. B. R. Jones. Ibid. 

" 19. Taken at or soon after birth ; lived two days. Dr. Sims, Amer. 
Jour, of Med. SeL, April, 1846. 

" 20. Taken at the age of six days ; lived one day. Ibid. 

" 21. Taken when three days old ; lived two days. Ibid. 

" 22. Male ; taken at the age of eight days ; died in three hours. 
Communicated to the writer. 

" 23. Taken at the age of twelve hours ; lived two days. Communi- 
cated to the writer. 

" 24. Female ; taken when seven days old ; lived forty-five hours. 
The writer. 

" 25. Male ; taken at the age of seven days ; lived about forty-eight 
hours. Ibid. 

" 26. Female ; taken at the age of eight days ; lived three clays. Ibid. 

" 27. Female ; taken at the age of five days ; lived three days. Ibid. 

" 28. Female ; taken when four days old ; lived two days. Ibid. 

" 29. Taken when six days old ; died next day. Ibid. 

" 30. Taken when five days old ; lived twenty-four hours. Ibid. 

" 31. Taken when eight days old; lived two days. Ibid. 

" 32. Male ; taken when five days old ; lived one day. Ibid. 

Favorable Cases. 

Case 1. Negro ; female ; taken when three days old ; recovered in a few 
days. Robert S. Baily, Charleston Med. Jour, and Rev., Nov. 
1848. 

2. Negro ; taken at eleven davs ; recovered in fifteen days. W. 
B. Lindsay, N. 0. Med. Jour., Sept. 1846. 

3. Negro ; taken when ten days old ; recovered in thirty-one days. 
P. C. Gaillard, Charleston Med. Jour, and Rev., Nov. 1853. 

4. Male ; taken at the age of eight days ; recovered in twenty-eight 
days. Ibid. 

5. Negro ; taken at seven days ; recovered in fifteen days. Au- 
gustus Eberle, Missouri Med. and Surg. Jour., 1847. 

6. Taken when eight days old ; recovered in four weeks. Furlong, 
Edin. Med. and Surg. Jour., Jan. 1830. 

7. Taken at the age of one week ; recovered in two days. Dr. 
Sims, Amer. Jour, of Med. Sci., April, 1846. 

8. Female ; taken at the age of three days ; recovered in five weeks. 
The writer. 

Period of Commencement. — Finckh, 1 who saw cases of tetanus of 
the newborn in the Stuttgart Hospital, states that it began in one case 
on the second day after birth, in eight on the fifth, and in seven on the 
seventh. 

Professor Cederschjold, of Stockholm, treated forty- two cases in hos- 
pital practice in 1834, and in these cases it usually commenced between 
the ages of four and six days. Copland 2 says that it generally com- 
mences in the first seven or nine days after birth, and rarely later than 
the fourteenth. Romberg states that it commences between the fifth 
and ninth days. In two hundred cases observed by Reicke, in Stutt- 

1 Hecker's Annalen, vol. Hi., No. 3, p. 304. 2 Medical Dictionary. 



488 



TETANUS INFANT I'M 



gart, in the course of forty-two years, it was never found to commence 
before the fifth, rarely after the ninth, and never after the eleventh day, 
Schneider says that the disease occurs oftenest between the second and 
seventh, and rarely after the ninth day. In six cases reported by Dr. 
C. Levy, of Copenhagen, it began in two on the third day, in tw r o on 
the fifth, and in two on the sixth. Dr. Greenville Dowell, who has 
seen much of tetanus infantum among the negroes in Mississippi and 
Texas, says it is almost sure to come on between the fifth and twelfth 
days after birth. In the forty cases embraced in the above table, the 
disease began as follows : 

Age. Cases. 

Under two days .2 

Two days . .' 1 

Three days 9 

Four days . . . . . . ■ . . . .2 

Five days 6 

Six days 3 

Seven days ........... 8 

Eight days 6 

Ten days 1 

Eleven days 1 

Twelve days ........... 1 

Very rarely, as will be seen hereafter, tetanus begins at or so soon 
after birth, that it may properly be called congenital. 

Frequency in Certain Localities. — Tetanus infantum occurs 
probably in all countries, but it does not greatly increase the mortality 
except in certain localities. Some of the British and Continental 
physicians, whose observations of disease have been ample, confess that 
they have seen so few cases that they have almost no personal knowl- 
edge of this malady. On the other hand, there are, or have been, 
places in every zone where it is or has been so prevalent as to check sen- 
sibly the increase of population. The attention of the profession, more 
than a half century since, was directed to the prevalence of tetanus in 
the Island of Heimacy, off the coast of Iceland. On this island scarcely 
an infant escaped, while on the mainland scarcely one was affected. 
Heimacy, the product of volcanic action, of small extent and almost 
destitute of vegetation, supports a scanty population. The inhabitants 
live chiefly on the flesh and eggs of the sea-fowl,* and are filthy and 
degraded in their habits. About the year 1810, the Danish govern- 
ment deputed the landphysicus of Iceland to visit Heimacy, and ascer- 
tain the nature of the disease which was so destructive to the infants. 
Although this gentleman, from his brief stay, saw no case himself, he 
obtained interesting particulars in reference to the disease from the 
priests and parents. At this time scarcely an infant escaped. Again, 
according to Dr. Schleisner, whose report in reference to the same 
locality was published forty years later, tetanus was still the most fatal 
of all infantile maladies. 

Tetanus infantum is also represented as very fatal in the Island of 
St. Kilda, off the coast of Scotland. In the temperate regions of 



1 Amer. Jour, of Med. Sci., Jan. 1863. 



causes. 489 

America and Europe cases are not frequent, except occasionally in the 
poor quarters of cities, in foundling hospitals, and rarely in country 
towns where the conditions are favorable for its occurrence. The 
records of the Dublin, Stuttgart, and Stockholm lying-in asylums fur- 
nish many cases. In the town of Fulda, Germany, in 1802, Dr. 
Schneider saw six cases in fourteen days, while a midwife in the same 
place stated that she had seen more than sixty in nine years. 

But the greatest mortality from tetanus infantum is in the warm 
climates, both of the Eastern and Western Hemispheres. In the West 
Indies, the southern portion of the United States, the equatorial regions 
of South America, and in the islands of Minorca and Bourbon, it has, 
in many localities, been the most frequent and fatal of infantile maladies. 

It is an interesting fact that in the warm regions of the United States 
the victims are chiefly negro infants. L. S. Grrier, x M.D., of Mississippi, 
says : " The first form of disease which assails the negro among us is 
trismus. The mortality from this disease alone is very great. No sta- 
tistical record, we suppose, has ever been attempted, but from our indi- 
vidual experience we are almost willing to affirm that it decimates the 
African race upon our plantations within the first week of independent 
existence. We have known more than one instance in which, of the 
births for one year, one-half became the victims of this disease, and that, 
too, in spite of the utmost watchfulness and care on the part of both 
planter and physician. Other places are more fortunate, but all suffer 
more or less ; and the planter who escapes a year without having to 
record a case of trismus nascentium may congratulate himself on being 
more favored than his neighbors, and prepare himself for his own allot- 
ment, which is surely and speedily to arrive." Dr. Wooten 2 says : "It 
is a disease of fatal frequency on the cotton plantations in this section of 
Alabama." He has, however, never seen a white child affected with it. 

While tetanus infantum prevails in regions wide apart, and present- 
ing very diverse climatic conditions, there is a similarity as regards the 
personal and domiciliary habits of the people w T ho suffer most from its 
occurrence. It occurs chiefly among those who are filthy and degraded 
in their habits, who live, either from choice or necessity, in neglect of 
sanitary requirements. This fact aids us in an understanding of the — 

Causes. — That uncleanliness and impure air are causes of tetanus 
is as fully demonstrated as most facts in the etiology of diseases. The 
attention of the profession was forcibly directed to this cause by Dr. 
Joseph Clarke in a paper read before the Royal Irish Academy in 1789. 
This physician was in charge of the Dublin Lying-in Asylum, and had 
rightly concluded that the mortality among the newborn infants was 
due to imperfect ventilation. Through his advice, apertures, twenty- 
four inches by six, were made in the ceiling of each ward ; three holes, 
an inch in diameter, were bored in each window frame ; the upper part 
of the doors leading into the gallery were also perforated with sixteen 
one-inch apertures, and the number of beds was reduced. The results 
of these simple sanitary regulations may be seen from Dr. Clarke's own 

1 1ST. 0. Med. and Surg. Journ., May, 1854. 

2 Ibid., May, 1846. 



490 TETANUS INFANTUM. 

statement. He says : " At the conclusion of the year 1782, of 17,650 
infants born alive in the Lying-in Hospital of this city, 2944 had died 
within the first fortnight, that is, nearly every sixth child." The dis- 
ease in nineteen cases out of twenty was tetanus. After the wards 
were better ventilated, namely, from 1782 till the time of the prepara- 
tion of Dr. Clarke's paper, 8033 children were born in the hospital, and 
only 419 in all had died, or about one in nineteen. So impressed was 
Dr. Evory Kennedy, who at a later period had charge of the same 
asylum, with the belief that Dr. Clarke had discovered the true cause, 
and had been able in great measure to prevent it, that he enthusias- 
tically writes: " If we except Dr. Jenner, I know of no physician 
who has so far benefited his species, making the actual calculation of 
human life saved the criterion of his improvements." The cases occur- 
ring in my own practice have almost all been in tenement-houses, where 
habits of cleanliness are not observed, and I have not yet seen, in the 
practice of others, nor heard of a case which occurred in the better class 
of domiciles. The statements of physicians in the Southern States, who 
speak from extensive observation among negroes, are strongly corrobo- 
rative of the belief that the disease is in great measure due to unclean- 
liness and lack of pure air. 

Dr. Greenville Dowell, of Texas, states that he has been able to trace 
tetanus infantum to the bedclothes, saturated with excrementitious mat- 
ters, which are found in the negro cabins. In a paper published by 
Prof. John M. Watson, 1 the frequency of this disease among negroes 
is accounted for as follows : 

" When called to see their children, we find their clothes wet around 
their hips, and often up to their armpits, with urine. . . . The 
child is thus presented to us, when, on examination, we find the um- 
bilical dressings not only wet with urine, but soiled, likewise, with feces, 
freely giving off an offensive urinous and fecal odor, combined at times 
with a gangrenous fetor arising from the decomposition, not desiccation, 
of the cord." 

Another cause is believed to be some irritation in the intestines, as 
from retained meconium. Observers in the Southern States and else- 
where occasionally mention this as a cause. In one case treated by 
myself, there was obstinate constipation immediately before the attack, 
and in another diarrhoea preceded, and was the only apparent cause. 

In certain cases the assignable cause is exposure to wet or cold, or to 
a variable temperature, which, it is known, occasionally causes tetanus 
in the adult. Prof. Cederschjold attributed the epidemic which he 
observed in Stockholm to a sudden change of temperature from hot 
weather in May, to frosty in June. In a case related by Dr. P. C. 
Gaillard, 2 the disease commenced as follows : The nurse came in with 
wet apron and clothes, in the evening ; a short time after she had taken 
the child into her lap, it sneezed violently two or three times. At 10 
p. M. tetanus began. In certain localities on the continent, where 
there are no parish churches, the frequent occurrence of tetanus 

1 Nashville Journ. of Med. and Surg., June, 1851. 

2 Southern Jour, of Med. and Pharmacy, Sept. 1846. 



CAUSES. 491 

has been attributed by physicians to the practice of carrying infants 
to a distance to be christened, thus exposing them to winds. In this 
city I have observed tetanus after a similar exposure. The influ- 
ence of the weather in the production of tetanus of the newborn is also 
shown by facts observed in the Stuttgart Hospital. In an aggregate 
of twenty-five cases treated in that institution, all but three occurred in 
the cold months. In the Island of Cayenne, at a hamlet surrounded 
by mountains and dense forests, tetanus attacked only one in every 
twelve or fifteen of the infants. After a great part of the forests had 
been cut down, so as to allow access to the cold sea winds, almost all 
the newborn infants fell victims to tetanus. (Insel, Cayenne.) 

Hein relates that a citizen of Berlin lost, successively, two children 
with tetanus soon after birth. When the second child fell ill he ob- 
served that its cradle was exposed to a current of air. At the third 
accouchement the position of the cradle was changed and the infant 
escaped. Exposure to wet and cold has been long recognized as a cause 
of the disease. According to Sauvages, " Hie morbus hieme et cum 
aura; humida ssepius advenit quam sicca sestate." 1 

The causes of infantile tetanus enumerated above may be proximate 
or remote, may produce the disease by their direct effect on the system 
or indirectly by causing a pathological state which in turn leads to the 
development of the disease. There are other direct causes, namely, 
organic affections. In the bodies of the newborn who die of tetanus," 
lesions are observed which doubtless result from the spasms. Again, 
others are found which, from their nature, could not be a result, and 
which, being observed in different cases, are to be regarded as causes. 
The most frequent of such lesions is inflammation of the umbilicus or 
umbilical vessels. 

Moschion, who lived in the first century of the Christian era, stated 
in writings still extant that stagnant blood in the umbilical vessels 
sometimes produced dangerous disease in the newborn infant, and it is 
supposed, though this is doubtful, that he referred to tetanus. In 
modern times the attention of the profession has been more particularly 
directed to this cause by a paper published by Dr. Colles. 2 The obser- 
vations contained in this paper were made in the Dublin Lying-in 
Hospital during a period of five years. In each of these years he 
witnessed from three to five post-mortem examinations in cases of 
infantile tetanus, and the lesions, he states, were in all much alike, as 
follows: The floor of the umbilical fossa was lined by a membrane 
apparently formed by suppurative inflammation, and in the centre of 
this fossa was a large papilla. This papilla consisted of a soft yellow 
substance, apparently the product of inflammation, and in all the cases 
the umbilical vessels were in contact with this substance and were per- 
vious. In a few instances superficial ulcerations were found near the 
mouth of the umbilical vein, and occasionally the skin surrounding the 
umbilicus was raised. The peritoneum covering the vein was highly 
vascular, often not to a greater distance than an inch above the umbili- 

1 ISTosol. Method, vol. i. p. 531. 

2 Dublin Hospital Keports, vol. i., 1818. 



492 TETANUS INFANTUM. 

cus, but sometimes as far as the fissure of the liver. The peritoneum 
in the course of the umbilical arteries presented the inflammatory ap- 
pearance in still greater degree, sometimes as far as the sides of the 
bladder. The connective tissue lying along the arteries and urachus 
anteriorly was loaded with a yellow watery fluid. The inner surface 
of the umbilical vein was not inflamed, but its coats, in general, were 
thickened. On slitting open the arteries, a thick yellow fluid, resem- 
bling coagulable lymph, was found within their coats, and in all cases 
these vessels were thickened and hardened as far as the fundus of the 
bladder. 

Dr. Finckh, who observed twenty-five cases in the Stuttgart Hos- 
pital, believes that the most frequent cause was suppuration or ulcera- 
tion of the umbilical cord. In ten of the twenty-five cases the navel 
was dry and cicatrized ; in the remainder it was either wet or swollen, 
with a bluish-red inflamed edge at the margin of the navel ; a dirty 
viscid pus covered the umbilical depression. 

Dr. Levy, physician of the Foundling Hospital in Copenhagen, 
attended twenty-two cases in that institution in 1838 and 1839. Of 
these twenty died, and fifteen were examined carefully after death. 
In fourteen there were decided marks of inflammation of the umbilical 
arteries, especially of those portions lying along the urinary bladder ; 
in several cases the peritoneum over the arteries was much injected, and 
in three adherent either to the omentum or intestine by coagulable 
lymph ; the coats of the arteries were thickened, their cavities dilated 
and containing dark reddish-brown or greenish puriform matter, always 
fetid. Sometimes the arterial tunica interna was found ulcerated and 
absent in places, and there was spongy thickening of the subjacent con- 
nective tissue. In two cases the ulcerative process had extended from 
the tunica interna to the peritoneum, and there was a deposit of thick 
ichorous matter around the ulcer; in one case both arteries were so 
softened that their coats were scarcely distinguishable, and in another 
these vessels had become gangrenous. The appearance of the umbilicus 
was unchanged in four cases ; in ten the fundus was red and filled with 
puriform fluid, which quickly reappeared when removed, and, in general, 
shortly before death, the navel presented a greenish color. 

According to Romberg, Dr. Scholler made post-mortem examinations 
in eighteen cases of tetanus infantum, and in fifteen' found inflammation 
of the umbilical arteries. These vessels were swollen near the bladder, 
in one case to the diameter of four lines, and were found to contain pus. 
The lining membrane was eroded or covered with an albuminous exu- 
dation. Both arteries were not always equally inflamed, and in three 
cases only one was affected. 

Schneeman 1 found minute points of suppuration in the umbilical vein 
in eight cases, and pus throughout the course of this vessel in one. 

The observations mentioned above were made, for the most part, in 
hospitals on the Continent ; but similar observations have been made 
in private practice. M. Borian, 2 of the Isle of Bourbon, says that he 

1 Holscher's Annalen, vol. v. p. 484, 1840. 

2 G-azette Medicale, Paris, July 11, 1841. 



causes. 493 

has found in every case inflammation around the umbilicus. Dr. John 
Furlonge, 1 who resided at St. John's, Antigua, attributes the disease to 
improper dressing of the umbilicus. The same opinion is expressed by 
Mr. Maxwell, 2 who also saw the disease in the West Indies. Dr. 
Ransom 3 states in a communication to Prof. John M. Watson, that he 
has never seen a case of tetanus of the newborn in which the umbilicus 
was healthy. In a case related by Robert S. Bailey, 4 there was a hard 
scab on one side of the umbilicus, and this part was much distended. A 
discharge followed the removal of the scab and the child recovered. In 
a favorable case, related by W. B. Lindsay 5 the umbilicus was tumid, 
and not disposed to heal. Dr. II. 0. Wooten 6 attributes the disease to 
the condition of the umbilicus and umbilical vessels, and states that he 
has found the umbilicus gangrenous. A case has been reported in 
which the umbilical vessels were blocked up by purulent matter. 7 
Robert H. Chinn, 8 M.D., of Brazoria, Texas, believes one cause of the 
disease to be improper tying and management of the umbilical cord, by 
which a diseased state is produced, which extends to the umbilicus and 
thence to the viscera. At a meeting of the Obstetrical Society of 
Edinburgh, held April 24, 1850, Dr. Imlach related a case in which 
there was a dark and gangrenous appearance on the integument around 
the umbilicus, and the peritoneum underneath was also dark but not 
inflamed ; umbilical vein healthy ; a little fibrin in the left umbilical 
artery ; right umbilical artery much diseased ; its two inner coats ap- 
parently destroyed, and in their place a yellow pultaceous slough, in 
which pus-globules were discovered with the microscope. 

It is evident that the pathological state of the umbilicus and umbilical 
vessels described above, and which has been noticed by so many ob- 
servers in different countries, cannot result from the tetanus. It is pos- 
sible that the puriform substance noticed in the umbilical vessels was 
disintegrated fibrin, which had coagulated at the time of ligation of the 
cord, and the cells seen by Dr. Imlach and others may sometimes have 
been white corpuscles still remaining from the stagnated blood. 9 Still 
the evidences of inflammation, in at least a part of the cases related 
above, were of a positive character. 

The belief that umbilical lesions occasionally cause tetanus infantum 
comports with the well-known traumatic causation of tetanus in the 
adult. This belief is strengthened by the fact, which will appear further 
on in our remarks, that tetanus of the newborn, from being frequent in 
certain localities, has become infrequent through greater care in dress- 
ing and managing the umbilical cord. 

But there are cases of tetanus infantum in which there is no disease 
in or about the umbilicus. Dr. Finckh, of Stuttgart, examined the 
umbilical vessels in eleven cases without discovering any pathological 

1 Edin. Med. and Surg. Journ., Jan. 1830. 

2 Jamaica Phys. Journ., copied into the London Lancet, April 11, 1855. 

3 Nashville Journ., of Med. and Surg., June, 1851. 

4 Charleston Med. Journ. and Eev.,^Nov. 1848. 

5 N. O. Med. and Surg. Journ., Sept. 1846. 6 Ibid., May, 1846. 
7 Ibid., Mav 1, 1853. 8 Ibid., Sept. 1854. 
9 Virchow's Cellul. Pathol. 



494 TETANUS INFANTUM. 

change. Dr. Samuel B. Labatt, 1 master of the Dublin Lying-in Hos- 
pital, published a paper entitled " An Inquiry into an Alleged Connec- 
tion between Trismus Nascentium and certain Diseased Appearances in 
the Umbilicus." This paper was designed as a reply to the essay of 
Dr. Colles. Dr. Labatt relates several cases in which there was no 
disease of the umbilicus and umbilical vessels, and others in which the 
disease was so slight that it probably produced no injurious effect on 
the health of the child. Dr. James Thompson, 2 who spent considerable 
time in the tropical regions, says: "I have myself examined nearly 
forty cases of infants that have sunk under this complaint. In many I 
have looked at no other part but the navel, and have found it in all 
states ; sometimes perfectly healed, especially if the infants had lived 
several days; at other times a simple clean wound. When death 
occurred on the fifth or sixth day, the wound was frequently in a raw 
state. I never yet saw it in a sphacelated condition." This writer 
concludes from his observations that there are cases in which the cause 
is located elsewhere than in the umbilicus or umbilical vessels. Dr. 
John Breen 3 remarks : " From dissections ... we have never 
been able to discover any peculiar morbid appearance which would 
justify us in offering any explanation of the pathology of the disease." 
In my own cases there w T as no evidence of disease of the umbilicus or 
umbilical vessels so far as could be ascertained by external examination, 
and in one (No. 32) a careful post-mortem examination disclosed no 
lesion of these parts. 

The inference from the above observations is that, although umbilical 
disease may be an occasional, probably not infrequent, cause of tetanus 
infantum, cases occur in which such disease is not present, and we must 
look for the cause elsewhere. From the nature of tetanus infantum, 
the cerebro-spinal axis has been from time to time examined in those 
who have died of this malady, and occasionally sufficient cause has been 
found in this part of the system. 

I have alluded in another connection to a case from Billard, in which 
tetanic rigidity occurred in an infant three days old, as the result of 
spinal meningitis. That tonic spasms not infrequently occur in older 
children in consequence of meningeal inflammation is well known, and 
in some of the reported epidemics of infantile tetanus meningitis was 
really present, and was doubtless the cause of the tonic spasms. Such 
an epidemic was observed by Professor Cederschjold in Stockholm, in 
1884. Within a few months he treated forty-two cases, and, in ad- 
dition to the lesions which are known to result from tetanus, there was 
found in the bodies examined a plastic exudation at the base of the 
brain. Finckh, of Stuttgart, made twenty post-mortem examinations 
of those who had died of this disease, and in nine found spinal menin- 
geal inflammation. 

Meningitis in the newborn is, however, rare, and we must regard it 
as an exceptional cause of tetanus. 



1 Edin. Med. and Surg. Journ., April, 1819. 

2 Ibid., Jan. 1822. 

3 Dub. Journ. of Med. and Chem. Sci., Jan. 1836. 



causes. 495 

In 1846 there appeared from the pen of Dr. Sims, then practising at 
Montgomery, Alabama, a paper designed to show that tetanus of the 
newborn is produced by pressure exerted on the nervous centre, through 
depression of the occipital bone. In 1848 the same writer 1 published a 
paper, fully enunciating his theory as follows : " That trismus neona- 
torum is a disease of centric origin, depending on a mechanical pressure 
exerted on the medulla oblongata and its nerves ; that this pressure is 
the result, most generally, of an inward displacement of the occipital 
bone, often very perceptible, but sometimes so slight as to be detected 
with difficulty ; that this displaced condition of the occiput is one of the 
fixed physiological laws of the parturient state ; that when it persists for 
any length of time after birth it becomes a pathological condition, capa- 
ble of producing all the symptoms characterizing trismus neonatorum, 
which are instantly relieved simply by rectifying this abnormal dis- 
placement, and thereby removing pressure from the base of the brain." 
In both papers cases are narrated in support of this theory, but there 
are serious objections to this mode of explaining the occurrence of the 
disease. In the first place, if this explanation were correct, tetanus 
ought ordinarily to occur sooner, for the occiput is as much depressed 
posteriorly, and in the majority of cases more depressed at birth than 
at the period when it does actually commence. Pressure on the medulla 
would certainly be followed by immediate and marked symptoms, in- 
stead of an immunity for four or five days. 

Again, well-known facts in reference to the causation of tetanus 
infantum conflict with Dr. Sims's theory, as, for example, epidemics of 
the disease, its prevalence in one locality and absence in another, 
although no particular attention be given to the position of the infant, 
the diminution of the number of cases by greater attention to cleanli- 
ness, of which there is abundant proof. Moreover, there are many 
reported cases of this disease at the commencement of which there was 
no perceptible displacement of the occipital bone. 

The inequality of the cranial bones often observed in tetanus infan- 
tum should, in my opinion, be explained as follows : When the newborn 
infant becomes emaciated the volume of the brain is diminished, like 
that of the trunk or limbs, and the sinking of the occipital bone simply 
corresponds with the amount of waste in the cerebral substance. What- 
ever the disease in the young infant, if there be much emaciation, the 
parietal bones will usually be found more prominent than the occipital. 
Now, in fatal tetanus infantum emaciation is very rapid ; those fleshy 
and plump, if the disease do not speedily end, become pinched and 
wrinkled. Viewed in this light, the occipital depression should be 
regarded as a result, and not a cause, of the tetanus. 

Although we do not accept the theory which attributes tetanus in- 
fantum to occipital depression, there are a few cases on record in which 
it was apparently due to injury of the head received at birth. Dr. Sims 
has related one such case, that of a negro infant. The mistress, an 
observing lady, gave to Dr. Sims the following account of it : Its head 
was " mightily mashed. . . . The bones seemed to be loose. I 

1 Amer. Jour, of Med. Sci. 



496 TETANUS INFANTUM. 

got it to take a little boiled milk on the first day ; but it swallowed 
very little and very badly, for its jaws seemed to be locked. On the 
next day it took spasms and got stiff all over ; its hands were shut up 
tight, and its arms were bent up so (she placed her forearms at right 
angles). Every time I touched it the spasm would get worse all over, 
screwing up its face till it w T as the ugliest thing in the world ; and when 
the spasms wore off it looked as well as any other newborn baby. But 
then the stiffness never left it, and the spasms kept coming and going till 
it died." It lived two days. 

It is evident, from the description given by the mistress, that this 
was a case of tetanus commencing at or so soon after birth that it 
seemed almost congenital. The apparent cause was injury of the head, 
occurring in consequence of protracted birth, the infant being resusci- 
tated with, difficulty after several minutes. 

Dr. W. C. Sutton 1 published a similar case. The infant at birth was 
apparently dead, but was resuscitated so as to live eighteen hours in a 
state of tetanic rigidity. In cases in which tetanus begins at birth, 
doubtless, the cerebro-spinal axis is in some way affected ; but in the 
absence of post-mortem examinations, the exact nature of the lesion is 
uncertain. 

It is evident, therefore, that in this disease, as in eclampsia, the cause 
in different cases may be entirely distinct. Dr. James Johnson, many 
years ago, expressed his belief in the multiplicity of causes, and he had 
been a careful and intelligent observer in the West Indies. 

The causes may be arranged in two groups, one external, the other 
internal. In the first group should be placed imperfect ventilation, 
personal and domiciliary uncleanliness, and atmospheric vicissitudes ; in 
the second group, so far as ascertained, inflammation of the umbilicus 
and umbilical vessels, meningitis, and, rarely, injury of the cerebro- 
spinal axis during birth. 

The lesions resulting from tetanus infantum pertain chiefly to the cir- 
culatory system. In the cases examined by Professor Cederschjold, of 
Stockholm, already alluded to, the meningeal and cerebral vessels, and 
those of the spinal cord, the cavities of the heart, and the large vessels 
connected with the heart, were distended with blood. 

Finckh made post-mortem inspection of twenty cases in the Stuttgart 
Hospital, the bodies at death having been placed on their faces, in order 
to prevent any deceptive appearance from the gravitation of blood. In 
four he failed to detect any alteration in the spinal cord or its mem- 
branes, but in the remaining sixteen he found effusion of blood, in con- 
siderable quantity, the whole length of the spinal cord, between the 
bony walls and the dura mater. It should be stated, however, that 
spinal meningeal inflammation was present in nine of the sixteen, though 
the extravasation did not, probably, result from the inflammation, but 
from the tetanus. The blood in Finckh's cases was very dark, some- 
times fluid, at other times coagulated. In one case no change was 
observed in the appearance of the brain or its membranes. In the 
remaining nineteen, more or less extravasated blood was found on the 

1 Nashville Jour, of Med. and Surg., April, 1853. 



causes. 497 

surface of the brain, or in its interior. The substance of the brain was 
healthy, as also its membranes, except the congestion. The only 
abnormal appearance observed in the thoracic and abdominal viscera 
was strong contraction of some portion of the intestinal tube in five 
cases. Dr. West says : " The most frequent post-mortem appearances 
in these cases" — referring to tetanus infantum — "and that which I 
found in the bodies of all the four children whom I observed, consist 
of effusion of blood, either fluid or coagulated, into the cellular tissue 
surrounding the theca of the cord. Conjoined with this there is gener- 
ally a congested state of the vessels of the spinal arachnoid, and some- 
times an eifusion of blood or serum into its cavity. The signs of con- 
gestion about the head are less constant, though much oftener present 
than absent, and sometimes existing in an extreme degree ; while in 
one instance I found not merely a highly congested state of the cerebral 
vessels, but also an effusion of blood, in considerable quantity, between 
the skull and dura mater, and also a slighter effusion into the arach- 
noid cavity." Dr. Weber, of Kiel, also placed on their faces infants 
who had died of tetanus, and, without exception, found injection of the 
capillaries of the cord and spinal meninges and extravasation of blood. 
M. Matuszynski, according to Bouchut, ; ' has observed effusions of 
blood of variable quantity, in the cerebral pia mater, in the ventricles, 
and in the choroid plexuses, with considerable injection of the mem- 
branes of the. brain. He has also seen serous infiltration beneath the 
arachnoid, and serous effusion into the ventricles, accompanied by a 
diminution of the consistence* of the cerebral substance." In two cases 
examined by inyself there was intense injection of the cerebral men- 
inges and of the meninges of the upper part of the spine, but no 
extravasation w T as noticed. The spinal canal was not opened. In a 
third case, in which the spinal canal was opened, there was extravasa- 
tion in addition to the congestion ; this was especially observed along 
the spinal theca. 

Dr. H. 0. Wooten 1 states that he has made several post-mortem 
examinations, and has found the pathological appearances as uniform 
as in anv other disease, as follows: " Engorgement of the substance of 
the brain, and of the meninges lining the base of the brain, the medulla 
oblongata, and spinal marrow; liver congested." 

In a case related by Dr. Imlach before the Edin. Obst. Soc, April 
24, 1850, the upper part of the lungs was healthy, the posterior portion 
congested, and containing many dark points ; heart and liver healthy ; 
small intestines of a light brown color ; stomach and large intestines 
pallid ; there had been umbilical hemorrhage. 

Romberg states that he found in a child whose death occurred from 
this disease, such intense congestion of the veins and sinuses of the 
brain, that a slight touch, and the removal of the cranial bones, pro- 
duced extravasation of the partly coagulated and partly fluid blood. 
Dr. Sch oiler, on the other hand, found extravasation of blood in the 
spinal canal in only one case in eighteen. 

It is seen from the above observations, that tetanus of the infant is 

1 N". 0. Med. and Surg. Jour., May, 1846. 
32 



498 TETANUS INFANTUM. 

ordinarily accompanied by great passive congestion, which is especially 
marked in the cerebro-spinal axis, and that frequently extravasations 
occur from the distended capillaries. The embarrassment of respira- 
tion and the retarded circulation of blood consequent on the tetanic 
rigidity, afford sufficient explanation of this state of the vessels. 

Symptoms. — In many cases premonitory symptoms are absent, or 
are so slight as to escape notice. In some patients fretfulness precedes 
the attack, but no more than is often observed in those who continue 
in good health. The first symptom which alarms the parents, and shows 
the grave nature of the commencing disease, is inability to nurse, or 
evident pain and hesitation in nursing. Commencing with rigidity of 
the masseters, the disease gradually extends to the other voluntary 
muscles, and in the course of a few hours the muscles of the limbs, as 
well as of the trunk, are involved. Persistent muscular contraction, 
which is the pathognomonic feature of infantile tetanus, is developed not 
fully in the beginning, but by degrees in each affected muscle, so that 
it is not till after the lapse of several hours, perhaps even a day, that 
the greatest amount of rigidity is attained. Therefore, in the commence- 
ment of the disease, the limbs can be bent, and the jaw pressed open, 
more readily than at a subsequent stage, though with manifest pain to 
the infant. 

During the period of maximum rigidity, the jaws are fixed almost 
immovably, often with a little interspace between them, against which 
the tongue presses, and in which frothy saliva collects. The head is 
thrown backward and held in a fixed position by the stiffness of the cer- 
vical muscles. The forearms are flexed ; the thumbs are thrown across 
the palms of the hands, and are firmly clenched by the fingers ; the 
thighs are drawn toward the trunk ; the great toes are adducted, and 
the other toes flexed. Occasionally opisthotonos results from the ex- 
treme contraction of the dorsal and posterior cervical muscles. The 
infant can sometimes be raised without any yielding of the muscles, by 
one hand under the occiput and the other under the heels. 

The rigidity is liable to variation in its intensity, even after the full 
development of the disease. If the infant be quiet, especially if asleep, 
the muscles are partially relaxed to such an extent sometimes, in the 
first stages of the complaint, that the features have a placid and natural 
expression, though only for a short time. Frequent exacerbations 
occur in the muscular contraction, sometimes without any apparent 
cause, and sometimes produced by anything which excites or disturbs 
the child. Attempts to open the lips or jaws, or eyelids, or to bend 
the limbs, blowing on the face, or even the crawling of a fly upon it, 
occasions the paroxysm. 

During the paroxysm the eyelids are forcibly compressed, as well as 
the lips, which are either drawn in or are pouting ; the forehead and 
cheeks are thrown into wrinkles, and the physiognomy is indicative of 
great suffering. The unnatural positions of the trunk and limbs, which 
result from the muscular contraction, are increased for the moment; the 
head is more forcibly thrown back, and the limbs more strongly flexed. 
The muscular movements which occur during the paroxysms are some- 
times described as clonic spasms. There is indeed occasionally some 



SYMPTOMS. 499 

quivering of the limbs, and yet, as I have on different occasions noticed, 
so far from the muscular action being a clonic spasm, it is clearly tonic, 
and is intensified during the paroxysm. In fatal cases the paroxysms 
occur more and more frequently until the period of collapse. 

The crying of the child affected by tetanus is never loud, however 
great the suffering. It is variously described by writers as " whimper- 
ing " or " whining." It is of this suppressed character in consequence 
of the rigid state of the respiratory muscles and their imperfect move- 
ment. 

During the exacerbation respiration is suspended, or so imperfect, 
and the circulation so retarded, that the surface becomes of a deep red, 
almost livid, color. Sometimes epistaxis occurs, affording partial relief 
to the congestion, and sometimes, though less frequently, the blood 
forces itself from the congested liver along the umbilical vein, and escapes 
from the umbilicus. The intense passive congestion consequent on the 
tetanic spasm is general throughout the system, but extravasation of 
blood appears to be more common around the brain and spinal cord 
than elsewhere. 

The frequency of the pulse and respiration varies in different cases, 
and at different stages of the same case. They are often somewhat ac- 
celerated, but at other times are natural, or are even slower than in 
health. 

While the appetite of the infant, to appearance, is not diminished, 
the pain which it experiences in nursing is such that alimentation is 
necessarily deficient. It can be fed with a spoon for a time after it 
ceases to take food in the natural way, but artificial feeding soon fails. 
The milk placed in its mouth is in great part pressed back through the 
violence of the spasm which is induced by the attempt to feed it. 

In consequence of imperfect nutrition, the infant rapidly wastes away. 
There is no other disease, except the diarrhoeal affections, in which the 
emaciation is so rapid. In a case related by Dr. W. B. Lindsay, 1 the 
record states that "the infant was fat three days before, but was now 
emaciated." Romberg, who saw tetanus infantum in European hospi- 
tals, and Dr. Robert H. Chinn 2 , of Texas, both speak of the rapid ema- 
ciation. The trunk and extremities lose their fulness, and the features 
become pinched. Several observers have noticed the appearance of 
miliaria in this reduced state of system, especially around the shoulders, 
and sometimes a decidedly icteric hue appears on the skin. 

The condition of the intestines is not uniform. They may be relaxed, 
particularly if the disease be due to some irritation in them ; in other 
cases the stools are natural or constipated. 

It is often difficult to ascertain the state of the eyes, since attempts 
to open the eyelids bring on spasms and cause firm compression of the 
lids against each other. According to Sir Henry Holland, one of the 
first symptoms which occurred in cases on the island of Heimacy was 
strabismus, with rolling of the eyes. But this statement must be re- 
ceived with caution, since these cases were not seen by any physician, 

1 1ST. O. Med. Jour., Sept, 1846. 

2 1ST. O. Med. and Surg. Jour., Sept. 1854. 



500 TETANUS INFANTUM. 

and the information was obtained from the parents and priests. If true, 
the proximate cause of the disease in Heimacy would seem to be located 
in the cerebro-spinal axis. Contraction of the pupils commonly occurs 
in the stage of collapse. 

Mode of Death. — Death in infantile tetanus may occur from apnoea 
in the paroxysms, from extreme congestion of the cerebral vessels, or 
apoplexy ; and, lastly, it may occur from exhaustion. The last mode 
is, probably, the most frequent. 

Prognosis. — All wricers till recently agree that tetanus of the infant 
rarely terminates favorably. Cullen attributes the ignorance of phv- 
sicians in regard to this disease to the fact that it is so little amenable 
to treatment that they are not usually summoned to attend those affected 
with it. In the Island of Heimacy, of one hundred and eighty-five 
cases occurring during a series of years about the commencement of the 
present century, not one survived ; and in the same locality, at West- 
mannoe, a small islet, sixty four per cent, of all the infants born died of 
trismus. (Report of Dr. Schleisner.) Similar statements in regard to 
the mortality of tetanus infantum are given by physicians in the Southern 
States. Dr. H. 0. Wooten, 1 of Alabama, says that he has " never seen 
a decided case of tetanus nascentium that did not prove fatal, 
and that it is very generally deemed useless to call in medical aid after 
the initiatory symptoms are well declared." Mr. Maxwell, 2 speaking 
in reference to the West Indies, says : " From observations which I 
have made for a series of years, . . . I found that the depopulat- 
ing influence of trismus nascentium was not less than twenty -five per 
cent. It scarcely has a parallel within the "bills of mortality." Dr. D. 
B. Nailer 3 says : " About two-thirds of the deaths among the negro chil- 
dren are from this disease, and so uniformly fatal is it, that a physician 
is never sent for." 

Yet death does not always result. Eight of the forty cases in my 
collection recovered ; but a correct opinion cannot be formed from this 
of the actual ratio of favorable to unfavorable cases, since favorable cases 
are much more likely to be published. In the history of these eight 
cases, two interesting facts are noticed, which, when present may serve 
as a ground for hope of a successful termination. These were, the age 
at which the disease began, and the fluctuation in the symptoms. With 
two exceptions, the infants who recovered were about a week old when 
the initiatory symptoms apppeared, and there were fluctuations in the 
gravity of the symptoms ; whereas, fatal cases ordinarily grow progres- 
sively worse. Yet, in favorable cases, the symptoms are never so severe 
as they become in a few hours in those who succumb. 

Duration in Fatal Cases. — Of eighteen cases observed by Finckh 
in the Stuttgart Hospital, fifteen died in two days, two in five days, and 
one in seven days. During the epidemic in the Stockholm hospitals, in 
1834, where forty- two cases were treated, the disease seldom lasted more 
than two days. Romberg says : " It generally lasts from two to four 

1 N. O. Med Journ., May, 1846. 

2 Jamaica Phv«. Journ., copied into the London Lancet, April 11, 1835. 

3 N. O. Med. Journ., Nov. 1846. 



PREVENTIVE TREATMENT. 501 

days, but its duration is at times limited at from eight to twenty -four 
hours, and occasionally, though rarely, it extends from five to nine days." 
In thirty-one fatal cases in my collection, in which the duration is 
mentioned : 



One lived 

Eleven others lived 
Twelve lived 
Pour lived. . 
Three lived . 



3 hours. 

1 day or less. 

2 days. 

3 days. 

4 days. 



Both Underwood, who published a little treatise on diseases of chil- 
dren in 1789, and Dr. Elsasser, at a more recent date, record fatal 
cases which were unusually protracted. The one described by Under- 
wood was treated in the British Lying-in Hospital, and, although all 
the others treated in this institution died by the third day, this lived six 
weeks ; but it is suggested by the author that death was due in part to 
some other affection. The child treated by Elsasser lived thirty-one days. 

Duration in Favorable Cases. — In the eight favorable cases in 
my collection, the duration of the disease, reckoned from the time when 
the infant ceased nursing till it began again, was as follows : In one case, 
two days ; in one, a few days ; in one, fourteen days ; in two, fifteen 
days ; in one, twenty-eight days ; in one, twenty-one days ; and in the 
remaining case, about five weeks. 

Diagnosis. — To one who has seen this disease in the newborn, or is 
familiar with its symptoms, diagnosis is easy. The symptoms which 
possess diagnostic value are more manifest and reliable than in most 
other infantile maladies. Permanent rigidity of the voluntary muscles, 
with temporary exacerbations, such as have been described above, which 
are induced by any cause which disturbs the infant — as attempts to open 
the mouth or eyelids — is pathognomonic. 

Preventive Treatment. — While tetanus infantum, if fully devel- 
oped, is ordinarily fatal, in spite of any remedial measures heretofore 
used, there is no doubt of the efficacy and value of preventive measures, 
when properly employed. This was shown by the great reduction in 
mortality in the Dublin Lying-in Hospital through the thorough ven- 
tilation introduced by Dr. Clarke. Dr. Meriwether, 1 of Montgomery, 
Ala., says : " When the disease appears endemically on a plantation, it 
may be arrested by having the negro houses whitewashed with lime, 
inside and out ; by raising the floors above the ground ; by removing 
all filth from under and about the houses; by particular attention to 
cleanliness in the bedding and clothes of the mother ; and in the dress- 
ing of the child, so as to prevent any of the matter from the umbilicus 
lying long in contact with the skin." Many physicians, especially in 
the Southern States, speak confidently of care in dressing the cord and 
attention to the umbilicus, as a means of prevention. Grafton 2 savs that 
he has " never known the disease to occur in any child whose navel had 
the turpentine dressing." He uses turpentine as follows: "At the 

1 Amer. Journ. of Aled. Sei., April, 1854. 

2 N. O. Aled. and Surg. Journ., July, 1853. 



502 TETANUS INFANTUM. 

first time, a few drops of undiluted turpentine are applied immediately 
to the umbilicus around the cord, and it is anointed at every succeeding 
dressing, the turpentine being diluted one-half or two-thirds with olive 
oil, lard, or fresh butter." This use of turpentine has also been recom- 
mended by other practitioners in warm regions. 

Dr. John Furlonge, 1 of St. John's, Antigua, believes that no case 
would occur with the following treatment : "The cord, when divided, 
should be wrapped in clean linen. Every night, for two weeks, one or 
two drops of tinct. opii and spts. vini, equal parts, should be given, and 
castor oil, with a little magnesia, every morning. The child must be 
washed in tepid water every morning, and the funis dressed." If this 
treatment be attended by the success which is claimed for it by Dr. 
Furlonge, so great care in dressing the cord is certainly well repaid in 
localities, as at Antigua, where a large proportion of the infants die of 
tetanus. 

Some experienced observers go so far as to assert that it is possible 
to ward off tetanus infantum after the occurrence of premonitory symp- 
toms. Dr. Dowell 2 says : " Some, with slight twitchings of the mus- 
cles, have recovered without any trouble by being put into a mustard- 
bath washed clean, and put in a clean and well-ventilated cabin." 

Treatment. — In considering; the effect of medicinal agents which 
have been employed in the treatment of infantile tetanus, the great 
difficulty which the child experiences in swallowing should be borne in 
mind. Without care, a considerable part of the dose is lost by the 
spasm of the muscles of deglutition, which ordinarily occurs when the 
spoon is placed in the mouth, so that, unless special attention be given 
to this matter, it is uncertain wdiether the prescribed dose is fully 
administered. 

The treatment employed by different physicians has been very 
diverse. Antiphlogistic remedies were prescribed by Finckh,but every 
case so treated was fatal. He states that whenever blood was ab- 
stracted, even in small quantities, the symptoms were aggravated. The 
same result has followed depletory measures in the practice of other 
physicians. 

The internal remedies which have been most frequently prescribed 
are opiates and antispasmodics. Furlonge, in a favorable case, gave 
laudanum, in doses of one drop every three hours,* alternately with two 
grains of Dover's powder. Woodworth also gave one-drop doses of 
laudanum; Eberle, one-sixth of a drop hourly. The opiate has gener- 
ally been given in combination with an antispasmodic. The Dover's 
powder, given every three hours by Furlonge, was combined with five 
grains of sulphate of zinc. The hourly doses of laudanum, by Eberle, 
were combined with six drops of tincture of asafoetida. 

When anaesthetics began to be employed in the treatment of diseases 
it was believed that they would be especially useful in cases of tetanus. 
Accordingly chloroform has been used in tetanus in the infant, with 
the effect of controlling the spasm during the time of its use, but with- 

1 Edin. Med. and Surg. Journ., Jan. 1830. 

2 Amer. Jour, of the Med. Sci., January, 1863. 



TREATMENT. 503 

out curing the disease. In Case 7 in our first table it was employed 
several times, but apparently without delaying the fatal result. The 
editor of the New Orleans Medical and Surgical Journal states, in 
the May issue of that periodical for 1853, that he has used chloroform 
in tetanus infantum, with the effect, he believes, of prolonging life. 
Anaesthetics certainly relieve the suffering of the infant, and on this 
account, even if they do not prolong life, their judicious employment 
seems proper. 

The remedy which, in my opinion, is far preferable to all others, is 
hydrate of chloral. Since the introduction of this agent into therapeu- 
tics, it has been employed by several physicians in the treatment of 
this disease with so good a result that it will probably supersede all 
other medicines for this purpose. Dr. Widerhofer, 1 of Vienna, states 
that he has saved six out of ten or twelve by the use of chloral. He 
prescribes it in doses of one to two grains by the mouth, or, if there be 
great difficulty in swallowing, two or four grains by the rectum. Dr. 
F. Auchenthales 2 relates a case in which he gave even six-grain doses, 
and in nine days the disease had entirely disappeared. I have recently 
employed hydrate of chloral in a case of tetanus, giving it in half-grain 
doses, every two hours, except when there was profound sleep. The 
disease was fully developed, and the symptoms severe when I was 
called. I did not believe that the infant with the old remedies Avould 
live more than two days, but by the chloral life was prolonged nearly 
one week. Moreover, by the use of chloral the suffering of the infant 
is greatly diminished. The frequent inhalation of sulphuric ether also 
aids materially in controlling the spasms. 

The administration of alcoholic stimulants is required at short inter- 
vals on account of the rapid emaciation and great prostration. 

Local treatment directed to the umbilicus in those cases in which 
there is evidence of inflammation of the umbilicus or umbilical vessels 
should not be neglected. The application of an emollient poultice to 
the umbilicus has been followed by apparent improvement, if we may 
believe the statement of some physicians who have made use of this 
treatment. Dr. Meriwether, of Alabama, says, if there be no im- 
provement from the medicine which he orders, he applies a blister, 
larger than a dollar, to the umbilicus, and with this treatment the 
child generally improves ; a remarkable statement, since so few im- 
prove at all. 

A warm foot-bath, repeated at intervals of a few hours, and stimu- 
lating embrocations along the spine, are proper adjuvants to the treat- 
ment. 

1 London Lancet, March 18, 1871. 2 Jahr. f. Kinderheil., N. S., iv. 



5C4 INTERNAL CONVULSIONS 



CHAPTEE XIII. 

INTERNAL CONVULSIONS 

[Spasm of the Glottis. Laryngismus Stridulus.} 

Young children are liable to temporary suspension of respiration, in- 
duced by violent emotions, especially by anger. In the midst of their 
excitement, while they are crying or screaming, their breath is suddenly 
held, as if from tonic spasm of the respiratory muscles. In a few sec- 
onds respiration returns and is natural. There is no stridulous inspira- 
tion or other unusual sound, and there is no apparent ill-effect, unless 
occasionally a degree of languor. External convulsions, which seem to 
be threatening, seldom occur, and when they do, are ordinarily mild. 
Some writers consider dentition the predisposing cause of this arrest of 
respiration, by inducing a sensitive state of the nervous system. Such 
an effect' of dentition is possible, but certainly many infants are affected 
in this manner before the as;e of dentition. 

A much more serious state, and one which is recognized as a true dis- 
ease, is that variously designated by writers as internal convulsions, 
spasm of the glottis, child-crowing, laryngismus stridulus, etc. Mani- 
fest difficulties attend the investigation of the pathological state in this 
disease. There can be little doubt that it is not precisely the same in all 
cases. That there is, during the paroxysms, tonic or clonic spasm of more 
or fewer of the respiratory muscles is inferred not only from the symp- 
toms pertaining to the respiratory apparatus, but from the fact that in 
severe cases spasms of the external muscles, as those of the limbs and 
face, often occur. Usually, also, the movements of the eyeballs indi- 
cate spasmodic contractions of the motor muscles of the eyes. The fact 
of spasmodic muscular action in parts that are visible justifies the belief 
that it occurs in other parts which are concealed from view, especially 
as the characteristic symptoms cannot be readily explained except on 
this supposition. Trousseau says: "Internal convulsions consist, then, 
principally in a spasm of the diaphragm and of the respiratory muscles 
of the abdomen and chest; but it occurs, also, that the muscles pertain- 
ing to the larynx are affected with spasm at the same time with these." 
Billiet and Barthez conclude from the symptoms that the "heart is not 
always a stranger to this internal convulsion, which, perhaps, prolongs 
itself even to the intestines." The muscles of the pharynx appear to 
be involved, in some cases, as well as those of respiration, rendering 
deglutition difficult. In one form of internal convulsions, namely, that 
which is principally referred to by writers, there is not complete arrest 
of respiration, but the inspirations, during the paroxysms, are difficult 
and are attended by a stridulous noise. Again the respiration may 
cease entirely, but when it commences it is stridulous, and difficult during 



CAUSES. 505 

a few inspirations. In still another form of the disease respiration 
ceases, but there is no symptom or sign indicative of glottic spasm or of 
an obstacle to the ingress of air ; the inspirations which succeed the 
paroxysm are easy and noiseless. It has been suggested that, in these 
cases, there is paralysis rather than spasmodic contraction of the respi- 
ratory muscles, but the symptoms may be explained in accordance with 
the commonly accepted opinion, namely, that there is spasm of the 
diaphragm and, perhaps, of certain muscles of the chest and abdomen, 
while the lar}<ngeal muscles are not affected. M. Herard, indeed, who 
has written one of the best monographs on internal convulsions, describes 
three forms of the disease, according to the supposed location of the 
spasm, namely, laryngeal, diaphragmatic, and another, which consists 
of a blending of the two. 

Internal convulsions are not frequent in this country ; they are rare 
in France, more frequent in Germany, and quite common in Englandt 
They occur, with few exceptions, before the age of two years. Dr. Wes. 
observed thirty-one cases under the age of two years, and only six above 
that age. 

Causes. — The causes of internal convulsions are not fully ascertained. 
Most observers have remarked the relative frequency of the disease dur- 
ing the period of dentition, and it is probable that dental evolution does 
operate as a cause, by rendering the nervous system more impressible. 

Spasm of the glottis has been attributed to enlargement of the thymus 
gland, and also to enlargement of the cervical and bronchial glands. It 
is presumed that this effect is due to the pressure of these glands on the 
par vagum, or the recurrent laryngeal nerve. It is certain, however, 
that there is no such enlargement of the thymus gland which could 
possibly produce glottic spasm, or any other form of internal convulsion 
at the age at which these convulsions commonly occur. This gland is 
largest in the newborn, and having no function after birth, it gradually 
becomes atrophied. If an enlarged thymus could produce glottic spasm, 
it would certainly occur most frequently in the newborn. Abnormal 
development of the thymus gland seemed to be the cause of atelectasis 
in two infants who died soon after birth in my practice, but I have not 
seen a case in which a convulsive attack was referable to this cause. M. 
Herard examined the thymus gland in six children who died of internal 
convulsions, and in sixty who died of other affections, and was not able 
to discover in its condition any causative relation to this disease. Indeed, 
cases have been reported in which the thymus had undergone more than 
its usual atrophy at the time when the convulsions occurred (Hasse). 
Enlargements of the lymphatic glands in the vicinity of the pneumo- 
gastric or recurrent laryngeal nerve may possibly give rise to glottic 
spasm, but this is doubtless an infrequent cause, if it be a cause at all, 
since these glands are often greatly enlarged in strumous and tubercular 
diseases without such a result. According to Dr. Jacobi: 1 "In some 
cases, described by Dr. Friedleben, a, congenital hypertrophy of the 
thyroid gland has probably been the cause of laryngismus. The patients 
were newborn infants of normal development, and born by normal labors. 

1 N". T. Journ. of Med., Jan. 1860. 



506 INTERNAL CONVULSIONS. 

There were no constitutional causes of the disease, but a remarkable 
vascular swelling of the thyroid gland. Whenever the swelling in- 
creased, the veins of the face and head increased in size also, the face 
grew livid, and the extremities and spinal column exhibited slight tonic 
convulsions. The recurrent nerves were entirely surrounded by the 
glandular tissue, their neurilemma looked unusually red, and their func- 
tions were probably injured during the occasional swelling taking place 
during lifetime." (Jacobi.) 

The cause is occasionally located in the cerebro-spinal axis. Thus 
Dr. Coley relates a case in which an exostosis arising from the internal 
surface of the occipital bone pressed upon the cerebellum, while nothing 
abnormal was discovered in other organs. Examples are also related 
in which the cause was located in the spinal cord. Thus Marshall 
Hall relates the case of a child with spina bifida, who was attacked with 
croup-like convulsions whenever it lay so as to press on the tumor. 

Internal convulsions are also frequent in rachitic softening and absorp- 
tion of the calvarium, since, when this is present, undue pressure occurs 
upon the brain, by the weight of the head of the child upon the pillow. 

In some patients there is evidently an hereditary predisposition to 
this disease ; those affected belonging to families in which a tendency 
to convulsive maladies is manifested. Thus Toogood states that five 
infants of the same family were affected with spasm of the glottis ; and 
Reid relates, on the authority of Powel, that of thirteen infants of the 
same parents only one escaped internal convulsions. 

The common predisposing cause is an excitable state of the nervous 
system, often associated with impaired general health. Hence the dis- 
ease is more prevalent in cities, where antihygienic conditions abound, 
than in the country. Hence, too, the frequent improvement when the 
patient is removed to the pure and bracing air of the country. The 
use of insufficient food, or food of a bad quality, must for the same rea- 
son be considered a cause, since it leads to impoverishment of the blood, 
and renders the nervous system more impressible. Facts mentioned by 
Reid and others show conclusively the influence of premature weaning, 
and the use of indigestible or otherwise improper aliment, in the pro- 
duction of this disease. 

The causes enumerated above are for the most part predisposing; oc- 
casionally they are the only apparent causes, since this disease some- 
times occurs when the child is tranquil, even in the midst of quiet 
sleep, or when it is at rest in its mother's arms. In other cases and 
more frequently, there is an exciting cause, often trivial. Anything 
that requires exertion on the part of the infant, or that excites strong 
emotions, may be a direct cause, as anger, or any of the violent pas- 
sions ; so may even coughing, or, in rare instances, attempts to swal- 
low. One author has known it to occur from excitement produced by 
examining the throat with a spoon. In a case in my practice, hereafter 
related, it occurred whenever the infant cried violently. It appears 
from the above facts that the etiology of internal convulsions is very 
similar to that of eclampsia. The same spasmodic muscular contraction 
may occur from a variety of causes. 



SYMPTOMS. 507 

Anatomical Characters. — While, therefore, structural changes in 
various parts of the system may give rise to internal convulsions, this 
disease, so far as ascertained, presents no anatomical characters, and 
must consequently be considered one of the neuroses. The lesions of 
the respiratory apparatus which are seen at post-mortem examinations, 
are due to the convulsions or are coincidences. Emphysema has some- 
times been observed as a result, it is believed, of the spasmodic and ir- 
regular respiration. It was present in all of Herard's cases, and Rilliet 
and Barthez consider it common in those who die of this affection, 
although they did not observe it in any of their cases. Slight emphy- 
sema in the upper lobes is, however, a common lesion in feeble infants, 
whatever the diseases of which they die. Therefore its occurrence in 
internal convulsions is probably due more to molecular change in the 
lungs, since these patients are cachectic, than to the irregular breathing, 
which is only momentary. 

In fatal cases of internal convulsions the blood is darker than usual, 
from an excess of carbonic acid ; and in some cases the cavities of the 
heart and large vessels are engorged with blood ; but in others they con- 
tain no more than the normal amount. More or less passive congestion 
occurs in the internal organs ; and congestion of the cerebral vessels is 
in some patients so great that transudation of serum occurs. 

Symptoms. — I have said that the symptoms vary according to the 
seat and function of the muscles which are affected. There is generally 
previous ill-health. The child is drooping, and is sometimes restless for 
days before the disease appears. Finally, if the muscles of the glottis 
become affected, the peculiar crowing sound is heard now and then dur- 
ing inspiration. It is observed especially when the child is crying or is 
agitated. It may be loud and well-defined from the first, but in most 
patients it comes on gradually, so that several days elapse before its full 
stridulous character is developed. The attacks are more frequent and 
severe at night, in or after the first sleep, than in daytime. 

Under favorable hygienic conditions, the malady may pass off with- 
out becoming more serious. In other cases the paroxysms gradually 
increase in frequency and severity. The dyspnoea in the attack is such 
that the features are livid, the head forcibly retracted, and death seems 
imminent from apnoea. In these severe paroxysms respiration often 
ceases entirely for a moment. When the spasm ends, a deep stridulous 
inspiration occurs, after which the breathing is natural. I have stated 
also that internal convulsions are often associated with those, usually 
tonic, but sometimes clonic, of the external muscles. In the tonic 
form, the thumbs are flexed across the palms of the hands, and some- 
times are grasped by the fingers ; the great toes are adducted, and the 
other toes flexed. In severe cases, the hands, forearms, feet, and legs 
are also somewhat flexed and rigid. At first, the contraction of the 
external muscles is temporary, either corresponding with the internal 
spasm, or it is most intense at the time of the spasm, though com- 
mencing sooner and subsiding later. After a while, however, if the 
disease continue, the spasmodic action of the external muscles becomes 
more persistent. In severe cases, nearly every inspiration is accompa- 
nied by the wheezing sound, and the paroxysms of dyspnoea are excited 



508 INTERNAL CONVULSIONS. 

by trifling causes. Anything that suddenly disturbs the mind or body 
may bring on the attack, as anger, the impression of cold, or currents 
of air. Dr. West calls attention to the fact that an anasarcous con- 
dition is sometimes present, accompanied by albuminuria. 

If the convulsions affect other muscles, as the diaphragm or the pec- 
toral and abdominal muscles, which are concerned in the respiratory 
function, while those of the larynx escape, respiration is irregular, or 
even suspended for a moment, but the stridulous laryngeal sound is 
absent, as there is no obstacle in the larynx to the entrance of air. In 
this form of the disease, the infra-mammary region may be strongly 
retracted during the paroxysm from tonic contraction of the diaphragm. 
In severe paroxysms, whether the spasm be laryngeal or diaphragmatic, 
consciousness is nearly or quite lost, the features may be pallid, or, if 
respiration be suspended, may be more or less livid. Relaxation of the 
sphincters of the bowels and bladder, with involuntary evacuations, 
often occurs in this disease during the attack. 

The duration of the paroxysm may be a quarter, a half, or even a 
whole minute. Total suspension of respiration for even half a minute 
involves danger. In mild cases there may be but few paroxysms, and 
they slight. In other instances they occur in a severe form, almost 
daily for several weeks or even months. In the following case the mus- 
cles of the larynx were apparently not involved. The patient was 
scrofulous, and has since had scrofulous periostitis, with necrosis and 
exfoliation of the surface of the tibia. At the time of the internal 
convulsions she had, as seen by the history, a scorbutic or hemorrhagic 
cachexia. 



Case. — On the 28th of August, 1858, a German female infant, fourteen 
months old, nursing, and having eight teeth, was suddenly seized with 
clonic convulsions. Uniformly delicate and pallid, she had been in her 
usual health till the age of twelve months, when she had a single convul- 
sive attack, and from that date had remained well till August 27th, when, 
without any premonitory symptom, she had a stool consisting of almost 
pure blood, black and offensive. On the morning of the 28th a similar 
evacuation occurred, and another in the afternoon immediately preceding 
the convulsion. Pulse 128, after the convulsion; surface cool and pallid; 
flesh soft, but no emaciation. Turpentine was prescribed in two drop 
doses every tw T o hours, and laudanum in one and a half drop doses, re- 
peated sufficiently often to insure quietude. 

On the 29th the pulse was 152. At 1 p. m. she had a general convul- 
sion, lasting about five minutes ; in the evening she had an evacuation 
similar to those passed on the preceding day. The record for August 30th 
states: "Pulse from 150 to 160; up to this time has been playful, but is 
now drowsy, and, when disturbed, fretful ; manifests no desire for solid 
food, as before her sickness, but still nurses ; has taken up to this time 
thirty-two drops of turpentine. When she cries or frets, she has a spas- 
modic attack." This was the commencement of internal convulsions, with 
which this child was affected for several months. An opportunity was 
afforded of observing their character, for her excitement, when she was 
examined, was usually sufficient to produce them. After a succession of 
short expirations, respiration ceased ; for a moment she was apparently 



PROGNOSIS. 509 

insensible; eyes closed; face pallid; no frothing at the mouth. The 
return of consciousness and respiration was without any laryngeal rale ; 
and after the attack she seemed as well as before. No external convul- 
sion and no evacuation of blood occurred after August 31st. 

There was gradual improvement in her health, but she continued for 
many months pallid and irritable, and subject to attacks of internal con- 
vulsions. On the 11 th of April, 1859, when twenty-two months old, she 
had another attack of general convulsions. The record made on that day 
is: " Has had internal convulsions (one or more paroxysms) almost every 
day since last August, brought on usually by crying, when she is corrected 
in any way, or her wishes are refused." Again, on December 1, 1859, it 
is stated : "Has grown considerably since the last record, and appears to 
have recovered, except that at long intervals the spasms still occur." 
She took a preparation of iron, but her recovery seemed to be due more 
to the growth and development of the body and to hygienic than thera- 
peutic measures. 

The general health in internal convulsions is more or less impaired, 
except in mild forms of the disease, in which the convulsive attacks 
soon cease. Pallor, or a sickly and cachectic aspect, irregular, usually 
constipated bowels, poor appetite, and moroseness or irritability of 
temper, are common symptoms of severe and protracted cases. 

Diagnosis. — This disease is easily diagnosticated, unless when its 
symptoms are masked by those of external convulsions ; it may then 
escape notice. Spasm of the glottis may be mistaken for spasmodic 
laryngitis, and vice versa. In some of the published cases this mistake 
appears to have been made. Spasmodic laryngitis is, however, so dif- 
ferent, not only in its nature, but in its clinical history, that a differen- 
tial diagnosis is not difficult. It is an inflammatory disease, and is 
attended with febrile reaction and a sonorous cough ; it commences at 
night after the first sleep, and from exposure to cold — particulars in 
regard to which it contrasts with true spasm of the glottis, which in 
complicated cases is not attended by any febrile symptoms. 

Prognosis — Modes of Death. — Statistics show great mortality in 
this disease. Dr. Reid, in a monograph on "Infantile Laryngismus," 
states that of 289 cases which he collated, 115 died. Rilliet and Bar- 
thez met with one favorable case in nine unfavorable ; and Herard, 
one in seven. If the paroxysms be mild, infrequent, and dependent on 
a cause which can be easily removed, recovery is probable with proper 
treatment. The cause may, however, be such, even when the spasm is 
mild, that the case is necessarily unfavorable : as when it is due to dis- 
ease of the cerebro-spinal axis. We should not, however, in any case 
consider the patient entirely safe, since grave symptoms may suddenly 
arise, so as to change entirely the prognosis. Long and severe par- 
oxysms, with lividity of face, and symptoms of suffocation, indicate an 
unfavorable result. The same should be predicted also if the infant 
gradually waste away, losing appetite and strength, especially if the face 
be pallid and the pulse feeble. 

There are three modes of death in internal convulsions. The first is 
apnoea. The infant dies suffocated in the attack. Respiration is first 
arrested, and then the pulse ceases, and at the autopsy the lungs and 



510 INTERNAL CONVULSIONS. 

the cavities of the heart are found engorged with dark blood. Death 
may also result from the state of the brain. In such cases, passive con- 
gestion of the brain occurs from obstruction to the return of blood from 
this organ to the heart and lungs; and if this congestion be not soon 
relieved, serous effusion also occurs. Death results from the congestion, 
and consequent oedema or dropsy. 

The third mode of death is from exhaustion. Repeated and severe 
attacks undermine the constitution ; the infant gradually grows pallid and 
thin, and dies of inanition, or of some disease which this state induces. 

Treatment. — The treatment of internal convulsions has varied ac- 
cording to the theories which physicians have held in reference to its 
cause. Glandular enlargement is no longer regarded as a common 
cause, and therefore treatment directed to its removal is less frequently 
prescribed than formerly. The causes of internal convulsions are in part 
very similar to those of eclampsia, and the remedies employed in the one 
affection are, in a measure, appropriate in the other. That dentition is 
sometimes a cause, is usually admitted ; and two cases, one of which 
occurred in my practice, and the other was reported to me, appeared to 
show that it may have a causative relation. The effect of dentition is 
especially observed in weakly infants, when several dental follicles are 
undergoing active evolution. Thus, in one of the cases to which I refer, 
five teeth pierced the gums in the course of two weeks ; after which no 
convulsive attack occurred. If, therefore, the gums are swollen, the 
propriety of scarification should be considered, especially if the convul- 
sions be so severe as to endanger life. 

In all cases of internal convulsions a careful examination should be 
made, in order to detect any aberration from the normal state which 
might cause nervous excitation. The condition of the digestive organs 
should be ascertained, and evacuants or other remedies prescribed if 
there be evidence of their derangement. 

Sometimes the alimentation of the infant is at fault. It is, perhaps, 
bottle-fed, and the stools have an unhealthy appearance. Attention 
should be given to the preparation of its food and the times of its feed- 
ing ; or, if it nurse, the mother or wet-nurse who suckles it, should have 
plain but nutritious diet, live with regularity, and give the breast to the 
infant at regular intervals. If there be a torpid state of the intestines, 
Dr. Meigs recommends "castor oil and aromatic, syrup of rhubarb 
rubbed up together, three parts of the former and five of the latter." 
A simple enema answers well in such cases, and, in debilitated infants, 
this is preferable to medicine administered by the mouth. If diarrhoea 
be present, and it persist after the requisite changes are made in regard 
to the diet, remedies calculated to relieve it, which are mentioned else- 
where, should be employed. Marshall Hall states that he has ordinarily 
succeeded in curing the disease by attending to the condition of the gums 
and digestive organs. 

Since rachitis is a not uncommon cause, the child should be examined 
in reference to the rachitic manifestations, and if they appear the treat- 
ment appropriate for rachitis is required. 

In pallid and cachectic infants, tonics are indicated. The elixir of 
Calisaya bark with iron in half-teaspoonful doses, three or four times 



TREATMENT. 511 

daily, to an infant of one year, is an eligible preparation. The com- 
pound tincture of bark, or of gentian, or the two mixed, may be given 
instead of the Calisaya bark. The preparations of iron are frequently 
to be preferred to the vegetable tonics, as the citrate of iron and bismuth, 
citrate of iron and quinia, the syrup of iodide of iron, or the wine of 
iron. To an infant of one year the syrup may be given in doses of 
three drops, the citrates in one-grain doses, and the wine in doses of 
one teaspoonful, every four hours. If the child be old enough, it may 
take iron in lozenges, as those of chocolate and iron. 

Antispasmodics, as asafoetida, valerian, and oxide of zinc, are often 
prescribed in this malady, but they are less efficacious than the general 
tonic measures which I have indicated. The salutary effect of bromide 
of potassium in eclampsia and epilepsy certainly justifies the trial of 
this agent in internal convulsions, if they persist after the employment 
of invigorating measures. 

Hygienic measures are of the utmost importance. The infant should 
reside in dry and airy apartments, and should be kept much of the time 
through the day in the open air. Remarkable success sometimes attends 
this simple expedient, when medicines have entirely failed. Mr. 
Robertson, 1 of Manchester, relates five severe cases in which this malady 
was cured by exposure of the infants several hours daily to a cool atmos- 
phere. These cases were treated in the winter months, and were kept 
outdoor, even during strong winds. Mr. Robertson has records of 
forty cases, all occurring between December and April, while he has 
seen no case in the summer months. As the result of such extensive 
experience, this writer recommends " the free exposure of the infant out 
of doors, for many hours daily, to a dry, cold atmosphere, and if the air 
be dry, the colder the better." Dr. Marshall Hall's experience was 
similar. Says he : " The curative influence of the air, and especially 
of the sea-breezes, is not less marked in this affection than in hooping- 
cough." Mr. Robertson recommends also, as part of the tonic treat- 
ment, " free sponging of the body every morning with cold water." In 
February, 1867, I attended a nursing infant, five months old, with in- 
ternal convulsions, the paroxysms being attended with lividity of the 
face, and, at times, tonic convulsions of the limbs. Among the reme- 
dies employed was bromide of potassium, but more benefit obviously 
accrued from keeping the infant much of the time in the open air, than 
from the medicines employed. The disease passed off in six or eight 
weeks. 

Unless the cause be of such nature that it cannot be removed, the 
above hygienic and therapeutic measures will, in a large proportion of 
cases, be followed by a satisfactory result. 

The mother or nurse may abridge the paroxysm by raising the infant, 
blowing upon it, sprinkling water in the face, or gently stroking it. 
Dr. Hall recommends tickling the nostrils with a feather, to produce 
respiration, or the fauces, to occasion vomiting, and thereby interrupt 
the paroxysm. Anything which produces a sudden and profound effect 
upon the system may abridge the attack. This w T as effected in one case, 

1 London Med. Gazette, Jan. 14, 1865. 



512 CHOREA. 

in the practice of Dr. C. D. Meigs, by applying a cloth wrapped around 
ice over the epigastrium and the lower part of the sternum. The chief 
danger during the attack is from congestion of the brain, with effusion 
of serum or extravasation of blood. If the attack be severe, and the 
features congested, so that there is evident danger of such a result, cold 
applications should be made to the head, derivatives used for the ex- 
tremities — as sinapisms, or mustard foot-baths — and the bowels should 
be speedily opened by enemata. 



CHAPTEE XIY. 

CHOREA. 

Chorea, or St. Vitus's or St. Gruy's dance, is a neurosis, which is 
characterized by irregular and involuntary muscular movements, with- 
out loss of consciousness. The movements occur in the muscles of voli- 
tion, and there is probably no one of them that may not be engaged, 
though some are more frequently aifected than others. It is not known 
that any involuntary muscle is ever involved, though Sir William Jen- 
ner has expressed the opinion that occasionally the papillary muscles of 
the heart are, so that, by their spasmodic contractions, they produce in- 
sufficiency of the mitral valve. This, according to him, affords expla- 
nation of the fact that, in certain instances, a mitral regurgitant murmur 
is heard, which disappears about the time that the external movements 
cease. It is rare, however, that a mitral regurgitant murmur, heard 
during chorea, ceases when the latter terminates, and it is not improb- 
able that in such cases there is, after all, a lesion of the valve, due to 
recent endocarditis, whether of a rheumatic or other origin. For a 
valve may be so thickened by recent inflammation as to cause a murmur, 
and after a few weeks or months the infiltrating i substance be so ab- 
sorbed that the murmur is no longer audible. If we admit the fact that 
cardiac bruits occasionally appear and disappear with chorea, this ex- 
planation seems to me more plausible than that of Jenner. Hillier 
says, in reference to this subject: "My own experience leads me to 
doubt the existence of dynamic apex murmurs in chorea, that is to say, 
murmurs produced in hearts entirely free from organic change. If such 
murmurs ever occur, they are certainly rare. Organic murmurs of the 
heart, on the other hand, are common in chorea, and I am inclined to 
believe that organic disease of the heart often exists in chorea when 
there is no murmur." We shall see that this opinion is correct, by a 
case presently to be related. Hillier also calls attention to the fact that 
choreic movements are irregular; but a cardiac bruit occurring regularly 
and uniformly, if not due to organic disease, would require rhythmical 



CAUSES. 513 

contractions of the papillary muscles to produce it. We infer from this 
that the bruit does not have a choreic origin. 

In the class of children's diseases in the Bureau for the Relief of the 
Outdoor Poor in New York City, 16,986 children were treated in the 
two years and three months ending with March 31, 1877. Of these 
cases 82, or one in every 207, had chorea. The patients were all under 
the age of fifteen years. Statistics published by observers in Europe 
show that the relative frequency of this disease is probably about the 
same in' the large European cities as in New York. Thus, according to 
Hillier, amongst 122,621 out-patients treated at the Hospital for Sick 
Children, in London, 406, or 1 in 322, had chorea; while of the in-pa- 
tients 174 in 5585, or 1 in every 32, were choreic. In the Parisian 
Hospital for Sick Children, of 84,968 admitted in twenty-one years, 531 
had chorea, or 1 in every 161. 

Age. — Chorea may occur at any period of life, but a large majority 
of the cases are in childhood. It is rare in infancy, and it rarely begins 
after puberty. Under the age of five years the proportionate number 
diminishes, as we approach the time of birth. The youngest in the sta- 
tistics of Hillier was three months. In 1870, in the Bureau for the 
Outdoor Poor a child was presented for treatment, w T ho the mother said 
had had chorea from birth, and in 1877 I treated a young woman with 
severe general chorea, who, repeatedly questioned, uniformly said that 
she had had the disease, without any assignable cause, from the first 
week of her life, and her friends corroborated the statement. The fol- 
lowing table exhibits the relative frequency of chorea at different ages : 

6 years 6 to 10 10 to 15 

and under. years. years. 

Children's Hospital, London, Hillier, none over 12 j^ears 

admitted 81 237 104 

M. Eufz 10 61 118 

Bureau for Outdoor Poor (prior to 1875) ... 2 26 16 

At and under 3 to 5 5 to 10 10 to 15 

3 years. years. years. years. 

Bureau for Outdoor Poor (since January 1, 1875) 5 30 237 130 

M. See collected the statistics of 531 cases occurring in the Chil- 
dren's Hospital, Paris, and from them concludes that the maximum 
frequency of chorea is between the sixth and tenth years. Only twenty- 
eight of his cases were under six years, the remainder, 503, occurring 
between the sixth year and puberty. 

Causes. — The profession are nearly agreed in regard to certain 
causes of chorea, while there is a diversity of opinion in reference to 
others. It is admitted that in a large proportion of cases there is a 
neuropathic state, which antedates and predisposes to chorea. This 
state is often manifested in the family history by a proneness to affec- 
tions of the nervous system, and in the individual by a highly excitable 
state of the emotions, so that he evinces joy, grief, or anger, from 
slight causes. 

All writers admit that there is often an inherited predisposition to 
chorea. In 27 of 48 cases, Radcliffe found that father, mother, brother, 
or sister had been or was the subject of one or other of the following 

33 



514 CHOREA. 

disorders: paralysis, epilepsy, apoplexy, hysteria, or insanity. The 
children of parents who when young had chorea, or who exhibit prone- 
ness to ailments of the nervous system, are more liable to chorea than 
other children. Hence the fact sometimes observed, of different chil- 
dren in the same family becoming affected with chorea when they attain 
the age at which this disease ordinarily occurs. In one family in my 
practice, three girls at different times were affected. 

Sex. — The emotions are strong in girls, since in them the nervous 
system predominates, while the muscular power is weaker than in boys. 
Hence a partial explanation of the fact which statistics fully establish, 
that the proportion of choreic boys to girls is about in the ratio of one 
to two and a fraction. I have remarked, in this city, the large propor- 
tion of cases in school-girls between the ages of six and twelve years ; 
the severe discipline and confinement of the public schools no doubt 
increasing the strength of the emotions, and weakening the control of 
the will over the muscles. 

Proportion of Males to Females. 

27 to 73. Hughes's Digest of Cases in G-uy's Hospital, 1846. 

138 to 393. M. See. 

50 to 94. Outdoor Department, Bellevue. 

276 to 499. Children's Hospital, London West (Lumleian Lectures). 

491 to 1059 = 1 to 2.15. 

The cases treated in the Outdoor Department, Bellevue, since those 
contained in the above table occurred, give a larger percentage of females. 
Between April, 1878, and December, 1883, 288 choreic cases were 
treated in this department, and of these the proportion of boys to girls 
was 1 to 2.4. (Chapin.) 

Uterine Irritation. — The peculiar changes occurring in the female 
at puberty constitute an important cause. Hence another reason of the 
excess of female cases. Dysmenorrhoea and pregnancy are causes of a 
large proportion of cases in the first years of puberty. In the male, on 
the other hand, the changes of puberty do not appear to increase the 
liability to the disease, directly or indirectly, and male cases, after the 
age of twelve years, are comparatively rare. Badcliffe 1 states that after 
the ninth year, females are more liable to chorea than males, in the 
proportion of 5 to 2 ; while before the ninth year, the two sexes are 
equally liable to it. Carefully prepared statistics, however, notwith- 
standing the high authority of Radcliffe, show a preponderance of girls 
under the age of nine years, though not so great as over that age. In 
the Outdoor Department at Bellevue, of 35 patients under the age of 
ten years, 22 were girls, while of 20 from the age of ten years to six- 
teen 15 were girls. 

According to West, 2 in 775 children with chorea, under the age of 
ten years, treated in the London Children's Hospital, 64 per cent, 
were girls. 

Anemia. — Among the most common predisposing causes of chorea 
is anaemia. It is present in so large a proportion of cases, exhibiting 

1 Reynolds's System of Medicine. 2 Lumleian Lectures. 



CAUSES. 515 

itself by pallor of the countenance and other characteristic signs, that 
medicines designed to improve the quality of the blood are among the 
most valued remedies. The peculiar neuropathic state already alluded 
to, which needs only a slight additional cause for the development of 
chorea, is, no doubt, largely dependent on impoverishment of the blood, 
if it be not sometimes due entirely to it. Among the poor of a large 
city like New York, or in hospital practice, the proportion of anaemic 
cases of chorea is, for obvious reasons, much larger than would appear 
from the general statistics. 

Rheumatism. — Dr. Copeland, M. Bouteille, and afterward M. Ger- 
main See, in a more extended monograph, directed the attention of 
the profession to rheumatism as a cause of chorea. Subsequent obser- 
vations have established the fact that rheumatism, or the rheumatic 
diathesis, is so frequently present that it obviously sustains an important 
relation to chorea, though in what matter is not fully ascertained. This 
relation between the two is more frequently observed in some countries 
than in others. In England and France, so large a proportion of 
choreic patients present a history of rheumatism either in themselves 
or family, that certain physicians of these countries believe that rheu- 
matism is the most common cause of the disease. In Germany, on the 
other hand, according to Romberg, in the majority of cases no relation 
can be traced between chorea and rheumatism. Probably the largest 
number of choreic cases treated in one institution in this country is in 
the Bureau for the Relief of the Outdoor Poor, in this city ; and it has 
been our practice during the last few years to examine each patient for 
heart disease, and question the parents as regards rheumatism. With- 
out referring to the exact statistics, I should say that more than half 
gave the history of rheumatism in themselves or parents, or had un- 
equivocal signs of heart disease. One of the physicians of the class 
found that 22 in 38 consecutive cases of chorea gave the history of 
rheumatism or of heart disease in themselves or parents. 

Various theories have been promulgated in explanation of the rela- 
tionship of the rheumatic and choreic diseases. It has been suggested 
that chorea is due to rheumatism of the brain or spinal cord. This is 
simply an hypothesis, the truth or falsity of which can only be ascer- 
tained by carefully conducted necropsies ; but the theory appears im- 
probable in view of all the facts. Another theory attributes chorea to 
the state of the blood which is present in those having rheumatism or 
the rheumatic diathesis, as well as in certain other conditions. This 
theory is enunciated by Dr. Ogle, as follows: a Recognizing the fre- 
quent existence of these fibrinous deposits or granulations on the heart's 
valves in chorea, I should be much inclined to look upon these post- 
mortem appearances rather as results of some antecedent general condi- 
tion of the blood, common also to the choreic condition. It is very 
freely recognized that this affection is frequently, in some way or other, 
connected with that condition of blood which obtains in what we call 
anasmia, or that existing in rheumatic constitutions. In both of these 
states we know that the fibrin of the blood is much in excess (as also it is 
in pregnancy, another condition looked upon as obnoxious to chorea) : 
and in these states we know that the fibrin with which the blood is sur- 



516 CHOREA. 

charged is very prone to be readily precipitated, either owing to its 
superabundance, or from other obscure and acquired properties . . . 
upon the heart's walls or valves. May not this hyperinosis be the ex- 
planation of the coincidence alluded to?" 1 — namely, the occurrence of 
chorea in those affected with rheumatism. Others still hold that chorea 
is the result of the heart disease, and not directly of rheumatism, occur- 
ring when the heart is affected from other causes, as well as when the 
lesion has a rheumatic origin. This theory is plausible, and probably to 
a certain extent correct. Heart lesions, observed in children, result from 
scarlet fever in a considerable proportion of cases, though it is true that 
the endocarditis and pericarditis of scarlet fever are believed often to 
have a rheumatic origin, occurring, in some instances, from scarlatinous 
rheumatism, but in other cases from scarlatinous uraemia. Occasionally, 
also, the heart disease appears to have occurred independently of both 
rheumatism and scarlet fever. Thus in a fatal case of chorea with val- 
vular disease, related to the London Pathological Society, April 6, 
1869, the child was always healthy up to the present illness (chorea), 
and there was no history of rheumatism in the family. The more ob- 
servations accumulate, the more important does heart disease in itself 
appear as a cause of chorea. In nearly all recorded cases of fatal 
chorea, which were supposed to be due to rheumatism, and in which 
post-mortem examinations were made, endocardial and usually valvular 
disease has been found. We shall see that certain eccentric causes of 
irritation aid in producing chorea, and may not the valvular disease, or 
the endocarditis which causes the valvular lesion, operate in a similar 
manner as a cause ? We know that in the adult severe cardiac disease 
often profoundly affects the nervous system, perhaps in consequence of 
the irregular and embarrassed circulation ; and certainly in the child a 
similar cause would be likely to produce a more decided effect. 

But there is an ingenious theory which attributes chorea to minute 
emboli detached from vegetations on the valves, and arrested by capil- 
laries in the corpora striata, or other portion of the cerebro-spinal axis. 
Since attention was directed to this matter, emboli have been found in 
one case in the medulla oblongata, although this portion of the spinal 
axis appeared healthy to the naked eye. Further observations are 
necessary in order to determine how much truth there is in this theory ; 
but it seems probable, for reasons to be stated, that .if capillary embolism 
do cause chorea, it is only in a limited number of cases, and that there- 
fore those British observers who regard it as the common cause, have 
been led into error by the large proportion of choreic cases which in 
their climate is complicated by valvular lesions. 

That embolism is not a common cause, if indeed a cause at all, appears 
probable from the following facts : First. In many cases of chorea there 
are no vegetations, or other appreciable lesions, which could give rise to 
emboli. Secondly. Most patients recover, and some speedily, by treat- 
ment, which we would not expect if the cause were embolism. Thirdly. 
Embolism is not infrequent in the cerebral vessels of the adult, without 
the occurrence of chorea. Indeed, the conditions which produce embo- 

1 British and Foreign Med.-Chir. Rev., January, 1868. 



CAUSES. 517 

lism are much more common in adults than in children, while the reverse 
is true as regards the liability to chorea. Fourthly. Dogs sometimes 
have chorea, but the injection of minutely divided fibrin or other sub- 
stance into the veins of the dog is not followed by chorea as one of the 
phenomena. Fifthly. Were capillary emboli the cause, we would ex- 
pect to find an occasional embolus in the larger vessels of the brain, so 
as to be appreciable to the naked eye ; but I find no examples of this 
in all the recorded autopsies which I have been able to consult. More- 
over, it seems improbable that capillary embolism, when producing no 
lesion appreciable to the naked eye, would so arrest the circulation, and 
disturb the function of the brain or spinal cord, as to cause chorea, for 
the ill-effects of such an obstruction would be likely to be obviated by 
the numerous anastomoses. 

In 1877 the unusual opportunity occurred, in my asylum practice, of 
determining whether there are any fixed anatomical characters in the 
cerebro-spinal axis in chorea ; in other words, whether chorea is a neu- 
rosis, as we have designated it in our definition, and the case is so inter- 
esting in other respects that I shall relate it entire. 

Case. — Charles, a foundling, born Oct. 15, 1874, was received in the 
New York Foundling Asylum soon after his birth. When two weeks old 
he was removed to a family in the city to be wet-nursed. His health con- 
tinued good till the age of three months, when he had bronchitis and kera- 
titis, the former mild, and lasting only a few days, but the latter continu- 
ing nearly two months, being attended by moderate injection of the con- 
junctiva, with some purulent discharge, which caused adhesion of the 
eyelids during sleep. From this time he remained well, with the excep- 
tion of a slight attack of dysentery, till the age of about nine and a half 
months, when he began to have febrile symptoms. In the morning hours 
he seemed in tolerable health, but at midday, or a little later than midday, 
of each day, he was observed to have slight irregularity or embarrassment 
of respiration, and lividity, with coolness of the extremities, which state, 
supposed at the time to be the algid stage of a somewhat irregular inter- 
mittent fever, lasted from one to two or three hours, and was succeeded 
by febrile movement, which continued during the remainder of the day ; 
sometimes the fever abated in perspiration. 

On August 4, 1875, a few days after the commencement of these irreg- 
ular febrile symptoms, Charles was brought to the dispensary of the insti- 
tution for treatment, and Dr. Keid, who was on duty that day, carefully 
examined the case, and prescribed the sulphate of quinia. This medicine 
continued a few days relieved the symptoms, but every four to six weeks, 
for more than a year, these febrile attacks returned, and were uniformly 
relieved by the same medicine. In other respects the patient had the 
usual health. 

On or about February 1, 1878, the nurse noticed that Charles had what 
she designated " spells of trembling," in which he seemed excited and 
feverish, and which were sometimes attended by or followed by perspira- 
tion. In the course of another week the irregular muscular movements 
became more marked and constant, and they increased in severity till near 
the time of the admission of the patient into the asylum, about March 1st. 
The nurse had noticed in February slowness and some difficulty of mictu- 
rition, and Dr. Keid examined him with a catheter for calculus, and also 



518 CHOREA. 

his prepuce for any source of irritation, but nothing abnormal was dis- 
covered, either in the condition of the bladder or the external organs. 
In the latter part of April, the chorea had become so severe, that irregu- 
lar muscular action occurred in all the limbs, and in the muscles of the 
eyes, producing such grimaces and contortions with strabismus, that the 
woman with whom he was boarding became alarmed, and returned him 
to the asylum, stating that he had become crazy. 

On March 12th my attention was first called to this child, when I made 
the following entry in my note-book : Family history unknown ; no 
history of rheumatism in patient's case, he may or may not have had it ; 
heart sounds normal; pulse 104; all the limbs and the muscles of the 
face, eyes, and eyelids involved in choreic movements, which continue 
constantly except during sleep. The patient cannot walk or stand with- 
out support ; appetite good, apparently better than in health, for he eats 
every kind of food handed to him, and carries the food with his own hand 
to his mouth, although these movements are very irregular and jerking. 
Three drops of Fowler's solution ordered after each meal. 

March 17. — Condition not much changed, but perhaps slight improve- 
ment ; in addition to other choreic movements the eyes twitch spasmodic- 
ally ; pulse 84 ; temperature 98 i° ; bowels regular ; no cough ; appetite 
good. Increase medicine to five drops. 

30th. — The urine examined since the last record was found very pale 
and abundant; its specific gravity low, 1040, without albumen. When an 
equal quantity of nitric acid was added to it, after twelve hours crystals 
of nitrate of urea occupied about one-half of the volume of the urine. 
The patient's sleep is quiet, but the choreic movements recommence as 
soon as he awakens, but in a milder form; is able to walk without sup- 
port, but with unsteady gait. My term of service ended March 31st. On 
the following day, laryngo-tracheitis was suddenly developed, ending 
fatally in forty-eight hours, at the age of two years five and a half months. 

Autopsy, April 4th. Slight oedema about the aperture of the glottis ; 
general and intense redness of mucous membrane of larynx, trachea, and 
bronchial tubes ; as far as they can be traced, posterior portions of lungs 
greatly congested. The heart, lungs, brain, with one eye attached to it 
by optic nerve, and the entire spinal cord were sent to Prof. Francis Dela- 
fielcl, for microscopic examination. They were, as soon as removed, placed 
in a solution of bichromate of potassium. The following is a brief state- 
ment of the examination, which was made. 

Microscopic Appearances. By Prof. Francis Delafield. Brain — 
presented no change apparent to the naked eye, except a considerable de- 
gree of congestion. It was hardened in bichromate of potassium and chro- 
mic acid. Minute examination of the convolutions of the brain, the large 
ganglia, the cerebellum, the pons Varolii, and the medulla oblongata 
showed nothing except a uniform filling of the vessels with blood, as if 
they were injected. There were no apoplexies, no changes in the walls of 
the vessels. 

Spinal cord — appeared to be entirely normal. 

The Heart. — The auricles and ventricles were of normal size. The 
aortic valves were atheromatous, and somewhat rigid ; the mitral valves 
were thickened and insufficient ; the endocardium of the left ventricle was 
thickened. 

The Lungs. — The capillaries in the walls of the air- vesicles were dilated, 
and there Avas an increase of epithelial cells within the air- vesicles. 

In this case there seemed to be no lesion associated with the chorea ex- 



CAUSES. 519 

cept the organic disease of the heart, and the changes in the lungs sec- 
ondary to this condition of the heart. 

The above microscopic examination was made with sufficient minute- 
ness, and it is seen that no emboli were discovered, and no lesion of the 
cerebro-spinal axis except congestion, which was attributable to the mode 
of death, namely, by obstructed respiration. Moreover it will be recol- 
lected that there were no cardiac bruits, and apparently not sufficient 
roughness of the edge or surface of the valves to cause precipitation of 
hbrin, wdiich would be necessary in order that emboli should form. 

Fright. — A not infrequent exciting cause of chorea is sudden and 
profound emotion, especially fright. All statistics give fright as the 
cause of a certain proportion of cases, though there are usually other 
potential cooperating causes, as anseniia or valvular disease. Fright 
was stated as the cause of chorea in 31 of the 100 cases occurring in 
Guy's Hospital, reported by Hughes, or nearly one in three. But the 
statistics of other observers do not give so large a proportion of cases 
originating in this way. Chorea may commence within a few hours 
after the fright, or not till the lapse of several days (eight or ten). If 
several weeks have passed since the fright, as in some reported cases, 
the chorea is probably due to other causes. In rare instances, chorea 
is said to have been caused by sudden and excessive joy. 

Imitation. — Under unusual circumstances, especially in a state of 
great mental excitement, imitation has been known to cause a form of 
chorea. Hecker describes an epidemic of it, occurring in the middle ages, 
and spreading through villages. In modern times it is rare that chorea 
originates from this cause, nevertheless occasional examples have been 
recorded. 

But the disease which occurs from imitation dhTers from the ordinary 
form, and has been termed chorea major ; while the chorea which is the 
subject of this article is sometimes designated, in contradistinction, 
chorea minor. 

In chorea major the patient leaps, dances, or whirls like a top. It 
has its origin commonly in religious excitement, and spreads by imita- 
tion almost in the manner of an infectious disease. The epidemic of 
the middle ages was a chorea major. I have not been able to find any 
account of cases spreading by imitation, in modern times, which w T ere 
not examples of the same form of chorea. Thus in the JEdin. Jour, 
of Med. and Surg., for July, 1839, there is a clear description of 
chorea major occurring successively in five children in the same family. 
Dr. Dewar, the attending physician, states that one of the children whom 
he was called to see was sitting near the fireplace, when her head dropped 
on her chest, and she appeared to doze some minutes. In the mean- 
time the respiration became a little accelerated, the face altered and 
flushed, the eyes wild. In less than one minute she bounded from one 
extremity of the apartment to the other, leaping over chairs, a chest, 
and then throwing herself upon the floor; she attempted to stand upon 
her head, rolled upon the floor, and then, rising, ran with extreme swift- 
ness in the room, till she finally fell again upon the floor, where she re- 
mained motionless some minutes. Then, recovering, she noticed those 



520 CHOREA. 

who surrounded her, and asked of her sister a toy, which she had al- 
lowed to fall. The whole paroxysm lasted twenty minutes. 

Obviously, the symptoms of chorea major differ materially from those 
of chorea minor, and it is a question whether it should have the same 
generic name. It is a curious and interesting disease in its psychical 
and pathological aspects, but it is so rare in modern times that a knowl- 
edge of it is of little practical importance. 

Intestinal Irritation. — In rare instances intestinal worms cause 
chorea, though in these cases there have usually been some cooperating 
causes. The following is an example related by Mr. Ogle 1 : " Ellen 
L., 9 years old, had been under treatment about a month with chorea, 
rheumatism, and worms. She had not slept in four days, and there 
was constant spasmodic movement of the body and face. Her general 
condition was very unpromising. As she had passed portions of a tape- 
worm at intervals during the last three months, one drachm of the oleum 
filicis maris was administered in mucilage, which caused the expulsion 
of the entire worm. From that time she fully and rapidly recovered 
from the chorea, though a mitral murmur remained." 

Lesions of Brain and Spinal Cord. — Although we reject the 
theory that cerebral emboli are the common cause of chorea, and believe 
that in a large majority of cases there are no cerebro-spinal lesions, 
nevertheless experiments, and also occasional cases, establish the fact 
that if not true chorea, at least choreiform movements now and then re- 
sult from a structural affection of the nervous centres. 

Experiments on certain of the lower animals demonstrate that irregular 
muscular movements may be produced by traumatic injury of certain 
portions of the cerebro-spinal axis, as the corpora quadrigemina, crura 
cerebri, pons Varolii, crura cerebelli, thalami optici, parts of the medulla 
oblongata and the upper portion of the spinal cord. Pressure on the pro- 
jecting part of the medulla oblongata of an acephalous monster also causes 
convulsive movements. At the meeting of the New York Academy of 
Meclecine, April 20, 1871, Professor Post related the case of a child who 
was struck over the occiput with a billet of wood, and chorea followed, 
due, in all probability, to the injury of the brain which resulted. 

If irregular muscular movements, choreic or choreiform, result from 
traumatic injury of certain portions of the nervous centres, may they 
not also occasionally occur from lesions of the same parts produced by 
disease? Sir Benjamin Brodie 2 relates the case of a choreic girl, dying 
in St. George's Hospital, in wdiom, after a careful post-mortem exami- 
nation, the only morbid appearance observed was a tumor the size of a 
hazel-nut, connected with the pineal gland. Dr. Broadbent 3 described 
another case before the London Pathological Society, in which a tumor 
was found arising from the centre of the spinal cord ; and Chambers one 
in which tubercles were embedded in the cord. Romberg quotes from 
Frerichs a case in which the medulla oblongata was pressed upon by an 
enlarged odontoid process ; and Dr. Aitken 4 one in which the specific 

1 Lond. Medico-Chir. Rev., Jan. 1868. 

2 London Lancet, Dec. 19, 1840. 

3 Transactions London Pathological Society, vol. xiii. p. 246. 

4 Glasgow Medical Journal, vol. i. 



AXATOMICAL CHARACTERS. 521 

gravity of the thalamus opticus and corpus striatum was greater on one 
side than on the other. Billiet and Barthez relate other similar cases, 
and add: "We may conclude, from these different cases, that there 
exist two species of chorea : the one essentially a simple neurosis, while 
the other depends on an alteration of the encephalo-rachidian system. 
In a word, it is of chorea as of convulsions, that it is sometimes idio- 
pathic, sometimes symptomatic." Still, the cases in which it is symp- 
tomatic are so few, that it is proper to consider chorea, as it ordinarily 
occurs, one of the neuroses until the microscope detects some anatomical 
cause in the cerebro-spinal system of which we are now ignorant. 

Axatomical Characters. — TVe have seen that chorea has no con- 
stant anatomical characters. Lesions which probably sustain a causa- 
tive relation to the disordered muscular action are sometimes present, 
and others are sometimes observed which are neither a cause nor result, 
their presence being a coincidence. But there are two lesions which, 
though often absent, have been observed in so large a proportion of 
fatal cases that they are justly regarded as an occasional result when 
chorea is severe. Dr. Hughes, of London, collected records of the post- 
mortem appearances of 14 cases, with the following result as regards the 
cerebro-spinal axis : Brain, 14 cases : healthy, 4 cases ; only congested, 
3 cases ; softened in part or entirely, 6 cases (some of these 6 also con- 
gested). In some of the 14 cases those occasional results of congestion, 
to wit, transudation of serum and extravasation of blood, in greater or 
less quantity, were also observed. Spinal cord : healthy, 3 cases ; con- 
gested, 2 cases (one slightly, in the other the engorged vessels were 
large and numerous) ; softening in medulla oblongata, 1 case ; softening 
opposite fourth and fifth vertebrae, 12 cases. In one there was soft, in 
another firm adhesion of the spinal meninges, and in one it is stated 
that the rachidian fluid was opaque. Of sixteen fatal cases of chorea 
occurring in St. George's Hospital, " congestion (more or less com- 
plete) of the nervous centres (brain or spinal cord, or both) was met 
with in six cases." Softening of certain parts of the brain was observed 
in one case, and of the spinal cord in another. 1 Other statistics of the 
anatomical character of fatal chorea correspond, in the main, with those 
of Hughes and Ogle. The lesions observed by them are probably not 
present in ordinary cases, occurring only when the choreic movements 
are so severe that the patient is deprived of needed repose, and the im- 
portant functions of the economy, as the circulation and nutrition, are 
seriously disturbed. 

The post-mortem examination of other parts besides the cerebro- 
spinal axis furnishes a negative result, if we except such affections as 
have been ascertained to act as causes of chorea. What portion of the 
nervous centre is chiefly involved in chorea is uncertain. Some, as Sir 
Benjamin C. Brodie, 2 consider chorea a disease of the nervous system 
generally, while others have attributed it to disease or disorder of a 
certain part, as the corpus striatum, cerebellum, etc. Finally, it is 
stated that, in late experiments on choreic dogs, the movements do not 

1 Ogle, Brit, and For. Medico-Chir. Kev., Jan. 1868. 



522 CHOREA. 

cease when the spinal cord is severed from the brain, nor also on 
division of the posterior roots of the spinal nerves. 1 In these cases, 
therefore, the part of the axis which is in fault would appear to be solely 
the spinal cord. 

Symptoms. — Chorea is partial or general. It is partial when it 
affects a few muscles, or groups of muscles, as those of one arm, the 
face or neck, or of one eye. It is designated general, when all the 
limbs, and certain of the muscles of the face and trunk, are involved. 
Statistics show that partial chorea occurs more frequently on the left 
than on the right side, and in general chorea the movements on the left 
side usually predominate. The commencement is, in most cases, gradual. 
Even when finally chorea becomes general, certain muscles only are 
affected in the commencement in ordinary cases. The child in whom 
this disease is about to begin is observed to be fretful and impatient from 
slight causes, and the irregular muscular action at first is apt to be mis- 
understood by the parents, who reprimand him for his supposed fidgety 
habit. In exceptional instances, especially when the cause is a sudden 
and profound emotion, the commencement is abrupt, and the disease is 
severe and general from the first. 

In a majority of cases the muscles which, are primarily affected are 
those of the face, neck, fingers, or hand on the left side. Sydenham 
erred, unless the clinical history of chorea has changed during the last 
two centuries, when he stated as the common fact that a tottering gait is 
its first manifestation ; but now and then such a case does occur. When- 
ever choreic movements appear, other muscles besides those first affected 
are soon involved, so that in the course of a few weeks, sometimes of a 
few days, all the muscles that participate are engaged. 

A muscle affected by chorea alternately contracts and relaxes, but 
less forcibly and rapidly than in eclampsia, and the movement is partly 
controlled by volition. This produces an unsteady and tremulous 
action of the part, whether a limb, the neck or face, which at once 
arrests attention, and indicates the nature of the disease. The result is 
similar, as regards the muscular action, whether the patient wills a 
movement, or attempts to control those which chorea produces. 

If the case be of ordinary severity, the movements continue with but 
momentary intermissions, except during sleep, when they ordinarily 
cease. In grave cases patients are often deprived of the proper amount 
of sleep, in consequence of the severity and persistence of the muscular 
action, and in exceptional instances, especially when the result is fatal, 
the movements continue in sleep, but the sleep is not sound, and is fre- 
quently interrupted. In profound sleep, the muscles are always in 
repose. 

The older writers have left us graphic descriptions of those diseases 
which have striking external manifestations, though often with some- 
what of exaggeration. Sydenham says of chorea : " The patient cannot 
keep it (his hand) a moment in the same place ; whether he lay it upon 
his breast, or any other part of his body, do what he may, it will be 

1 Legros et Onimus, Rech. sur Tes mouvements choreiformes du chien, Acad, des 
Sci., 9 Mai, 1870, Lyons Med. Jour., June 5, 1870. 



SYMPTOMS. 523 

jerked elsewhere convulsively. If any vessel filled with drink be put 
into his hand, before it reaches his mouth, he will exhibit a thousand 
gesticulations, like a mountebank. He holds the cup out straight, as if 
to move it to his mouth, but has his hand carried elsewhere by sudden 
jerks. Then, perhaps, he contrives to bring it to his mouth, and if so, 
he will drink the liquid off at a gulp, just as if he were trying to amuse 
the spectators by his antics ! ' ' 

In severe general chorea a similar description is applicable to the 
movements of the legs and features. Grimaces and distortions of the 
features occur, while the gait is halting and unsteady, or it is impossible 
to walk, and the patient lies or sits. The speech is slow, thick, and 
•indistinct, in consequence of the muscles of the tongue and larynx be- 
coming engaged, and even mastication and deglutition are rendered diffi- 
cult. The imperfect speech in chorea is attributed partly, however, to the 
mental state in severe protracted cases. Chorea, except when mild, is 
accompanied by other symptoms referable to the nervous system. More 
or less impairment of the mental faculties occurs in chronic cases when 
severe, exhibiting itself in dulness or apathy. The countenance some- 
times presents in aggravated cases almost the appearance of idiocy. The 
muscles, instead of becoming hypertrophied and more powerful by their 
frequent contraction, grow softer, more flabby, and weaker. Indeed, a 
partial paralysis sometimes results, so that a degree of numbness is ex- 
perienced in the affected part, and the limb when raised cannot be sus- 
tained. Pain is not a symptom of chorea, but fugitive rheumatic or 
neuralgic pains are sometimes experienced. Derangement of the diges- 
tive function, exhibited by a poor or capricious appetite, constipation, etc., 
are common. 

In rare instances chorea affects the respiratory muscles so as to pro- 
duce a peculiar involuntary barking or squeaking voice by the forcible 
expulsion of air over the tense vocal cords. In a case treated by Dr. 
L. C. Gray, in the N. Y. Polyclinic, the patient, a boy of fifteen years, 
had been choreic since his seventh year, and chorea in its usual form 
had continued one year when the barking sound commenced, and this 
has continued until the present time. Dr. French, of Brooklyn, also 
treated a similar case, having the following history : A boy of nine 
years, had choreic twitchings of the facial muscles at the age of five 
years. After continuing several months they ceased during an entire 
winter, after which the peculiar sound of the voice, resembling the 
squeak of a young turkey, commenced. It occurred at the beginning, 
middle, or end of respiration. It alternated with choreic movements of 
other parts of the system, so that when they ceased, it returned. By 
the laryngoscope, the irregular action of the vocal cords was observed, 
but the expiratory muscles of the chest were also involved, so as to 
produce the peculiar sound by the forcible expulsion of air. In Dr. 
French's case these vocal sounds ceased, except at rare intervals after 
three months of medicinal treatment. 1 

The urine of choreic patients has been examined by Drs. Walsh, Ford, 
Bence Jones, Handheld Jones, Radcliffe, and others, and its elements 

1 N". Y. Med. Kecord, Dec. 15, 1883, Dr. Chapin. 



521 CHOREA. 

have been found in most cases to vary from their normal quantity. Dr. 
Handheld Jones 1 read a paper before the Clinical Society of London, in 
1871, on two cases of chorea in which he had made careful chemical 
analysis of the urine, with the following result: During the height of 
the disease the amount of the urine was much in excess of what it was 
wdien the disease had ceased ; the urea excreted during the choreic 
period was in excess, as was also the phosphoric acid excreted when the 
choreic symptoms were at their maximum, but the quantity of this acid 
was less than the average during convalescence; a moderate amount of 
uric acid during the disease w T as also observed, but none upon recovery. 

Prognosis — Course. — Chorea, though obstinate and often incurable 
in adults, usually terminates favorably in children in two to four months. 
Bouchut considers its ordinary duration at from thirty to fifty days, 
which is certainly shorter than the average duration in this country, 
except when the disease is materially abridged by treatment. The same 
author states that it may continue only a few days, as he has observed 
in cases which occurred during convalescence from scarlet fever. But 
tremulousness of the muscles occurring in the state of weakness follow- 
ing a grave disease, and abating as the general health is restored, I 
should not consider as properly choreic, any more than that occurring 
from over-fatigue. As the choreic movements gradually increase in the 
initial period till a certain maximum is reached, so their decline is 
gradual. Temporary variations also occur throughout the disease as 
regards the extent of the movements, which are aggravated by mental 
excitement, bodily fatigue, certain functional derangements, especially 
of digestion, and sometimes from causes which are not apparent. 

Though, as a rule, chorea in children ordinarily terminates favorably 
under different, and even injurious modes of treatment, there are excep- 
tional cases. Romberg relates the history of a patient who died at the 
age of seventy-six years, having had chorea since the age of six years. 
In chorea limited to a few muscles, or a group of muscles, the prognosis 
is more doubtful than when it affects a large number, since in the former 
case the cause is more likely to be some lesion of the cerebro-spinal axis. 
Thus chorea involving only certain muscles of the neck or of the eyes is 
sometimes due to this cause, and is then very obstinate. 

Again, observations demonstrate that chorea, when at first in all 
probability strictly a neurosis, but of a protracted and grave character, 
may give rise to a central organic disease. This is the course of most 
of the fatal cases, congestion, softening, or other lesion occurring over a 
greater or less extent of the nervous centres. Radcliffe has known 
cerebral meningitis to supervene in two instances. With the occurrence 
of a lesion of the cerebro-spinal axis new symptoms arise, such as head- 
ache, convulsions, delirium, and paralysis, and the choreic movements 
cease or continue, according to the nature of the lesion. 

Chorea, like certain other diseases, either of a nervous character or 
having a nervous element, is more or less modified by intercurrent in- 
flammatory and febrile affections. The oft-quoted expression from Hip- 
pocrates, febris accedens solvit spasmos, observations show to be founded 

1 London Lancet, July, 1871. 



TREATMENT. o2o 

in fact, the most frequent example of which occurs in pertussis. In 
chorea the movements, as a rule, are either rendered milder or they 
cease as long as the febrile excitement continues ; but there are excep- 
tions, and the subsequent course of the disease is not modified. 

Diagnosis. — This is not difficult in ordinary cases. The irregular 
movements, with consciousness preserved, enable us to make a diagnosis 
at sight. In its commencement, and when it continues in an unusually 
mild form, chorea may be overlooked by the physician, as it often is 
by the parents, the movements being attributed to a fidgety habit : but 
medical advice is seldom sought till the movements are so pronounced 
that it is impossible to err, except through gross ignorance or care- 
lessness. 

It is important to determine when chorea merges in an organic dis- 
ease, and also whether there is a local cause of the chorea. A careful 
and intelligent study of the symptoms and history of the case is requisite 
in order to a correct diagnosis in these particulars. 

Treatment. Regimenal. — As chorea in a large proportion of cases 
occurs in a state of anaemia, and the vital forces are ordinarily more or 
less reduced, obviously the regimen should be such as invigorates the 
system. Fresh air and outdoor exercise, active or passive, according to 
circumstances, with the avoidance of undue excitement, are requisite, 
and the diet should be nutritious, but plain and unirritating. The 
various functions should be preserved so far as possible in their normal 
state. In exceptional instances, when the choreic movements are violent, 
the patient should lie in bed, and the muscular action, if so constant and 
excessive as to deprive him of the requisite sleep, should be restrained 
by light and well-padded splints. 

Medicinal. — Sometimes among the cooperating causes is one of a local 
nature, which is susceptible of removal, as a carious and painful tooth, 
intestinal worms, etc., and measures calculated to effect this are ob- 
viously required. Allusion has already been made to a case in which 
the employment of the oleo-resina filicis and the expulsion of a tape- 
worm effected a speedy cure. 

The remedy which has been most employed in chorea, and which in 
consequence of the anaemia is plainly indicated in a large proportion of 
cases, is iron. It does not interfere with the employment of other 
remedies which have a more specific effect. Nearly all the ferruginous 
preparations have been prescribed in different cases with benefit. Rad- 
cliffe gives the preference to the iodide of iron, believing that iodine, as 
well as iron, exerts a curative influence. I have of late inclined to the 
use of the ammonio-citrate, as it is easy of administration in simple 
syrup, and is well tolerated. 

But iron must not be regarded as the main remedy, but rather as an 
adjuvant. Observations during the last few years in both continents 
have more and more established the claims of arsenic to be regarded as 
the most efficacious of all medicinal agents in the treatment of chorea. 
Properly administered, it abridges the duration of this disease more 
certainly than any other agent, and within a few days begins to modify 
the choreic movements in the severest cases. It is conveniently given 
in the form of Fowler's solution. It is better tolerated by children 



526 CHOREA. 

than adults, and should be administered to them in a larger propor- 
tionate dose. A child of eight years can take five drops, diluted in 
water, three times daily after eating, and the dose may be increased if 
needed to eight, ten, twelve, or even fifteen drops. I have seldom ob- 
served any gastric irritability or other unpleasant effect from its use 
when it is administered largely diluted and after the meals, but if such 
occur, it should, of course, be suspended for a time. 

While not hesitating to recommend iron and arsenic as superior to all 
other medicines in the treatment of chorea, it is not proper to ignore 
the opinions of other members of our profession, who have had ample 
experience and recommend other agents instead. 

Trousseau gave the preference to strychnine, increasing the doses in 
some cases until it began to produce its poisonous effects. 

Professor Hammond l says : " My main reliance is on strychnia, 
which, I think, should be given in gradually increasing doses, some- 
what after the manner recommended by Trousseau. . . . This 
plan of treatment certainly shortens the duration of the disease very 
materially, and causes great improvement in the general health of the 
patient. Sometimes the effect is so well marked, and is so immediate, 
that it is not necessary to increase the doses to the extent of causing 
muscular cramps, but generally the full therapeutical effect of the drug 
is not obtained till the calf of the leg or the nucha has slight tonic spasm. 
I have never seen the slightest ill-consequence follow this mode of treat- 
ment, and the doses are increased so gradually that with careful watch- 
ing danger need not be apprehended." Dr. Hammond has treated 
thirty-two children with this agent without a single failure. 

But as chorea terminates favorably with smaller and safe doses, even 
if the time required be longer, it does not seem proper to recommend its 
employment to the extent of producing physiological effects for general 
practice. Bouchut, speaking upon this point, says : " But, with these 
precautions, strychnia is extremely dangerous, for I have seen, at the 
Hopital des Enfants Malades, a young girl of thirteen years die in 
tetanus," produced by an increased dose of this drug (article on Chorea). 
Dr. West, in his Lumleian Lectures, also says : "I have seen one in- 
stance in which its employment, while it failed to benefit a somewhat 
severe case of chorea, was followed by two attacks of violent tetanic 
convulsions, which nearly proved fatal;" and he adds, " The twitching 
of the limbs of itself prevents our becoming aware of the dose being 
excessive, and a child's inability to describe its sensations deprives us 
of another. For such reasons, Dr. West does not favor the employ- 
ment of this agent. Still, any agent may be given in an overdose, and 
it is not difficult to prescribe strychnia in a dose which will be efficient 
and yet safe for children at the age at which chorea ordinarily occurs. 
I have employed bromide of potassium in a few cases, but with so little 
benefit that I am not inclined to continue its use for this disease. 
Others have not been more successful. However efficacious the bromide 
may be in epilepsy, it does not appear to be a remedy for chorea. 

Cimicifuga, first employed by Jesse Young, of this country, is highly 

1 Diseases of the Nervous System, page G17. 



TREATMENT. 527 

esteemed by Philadelphia physicians in the treatment of chorea. I 
have employed the fluid extract in doses of half a drachm, increased to 
one drachm, for a child from six to ten years of age, and though it 
benefits some cases, it has no appreciable effect either in moderating the 
movements or abridging the duration of others. 

Ether, asafoetida, valerian, musk, the oxide and sulphate of zinc, tur- 
pentine, tartar emetic, opium, and numerous other remedies, have been 
recommended, and some of them have seemed useful in certain cases. 
In this city sulphate of zinc has been frequently employed as a remedy 
for chorea, and in gradually increasing doses till more than twenty 
grains were administered three times daily, but it has not appeared, so 
far as I have been able to ascertain, to exert any marked influence 
either on the severity or duration of the choreic movements. Justice, 
however, requires us to state that Dr. West, who has written recently 
on the nervous diseases of children, thinks that it has been beneficial in 
certain cases in which he has employed it, and he regards it on the whole 
as the best remedy. 

Radcliffe, who has had ample experience in the treatment of nervous 
affections, writes: " In an ordinary case of chorea the plan of treat- 
ment which I have now adopted as a rule for some time is to give cod- 
liver oil, in conjunction with hypophosphite of soda, making the draught 
containing the latter salt the vehicle for the administration of the cod- 
liver oil." Sometimes camphor or the sesquicarbonate of ammonia is 
added. Of more than thirty cases treated in this way, the average 
duration was under three weeks, Radcliffe began to prescribe these 
remedies on theoretical grounds, believing that phosphorus and cod- 
liver oil were required to restore " nerve tone," and the result of this 
treatment has certainly been such as to commend it to the profession. 
To children he gives from five to eight grains of the hypophosphite of 
sodium three times daily. 

In those severe cases in which choreic movements prevent the proper 
amount of sleep, a moderate dose of hydrate of chloral may occasionally 
be advantageously administered. 

Electricity has been many times employed in the treatment of 
chorea, and though some, chiefly electricians, believe that it has a 
curative effect, others, and the majority, fail to see any material benefit 
from its use. 

Cold general baths, the shower-bath, frictions along the spine, etc., have 
been employed ; but the local treatment which has so far been most success- 
ful, and which promises to supersede all other local measures, consists in 
the application of ether spray over the spine. About two ounces of 
ether are employed at each sitting, the spray being applied from an 
atomizer up and down the whole length of the spine if the chorea be 
general. The operation, which occupies from ten to fifteen minutes, 
should be repeated daily or every second day. A considerable number 
of cases have been reported, in which the spray has apparently had a 
good effect in controlling the disease. But I repeat my belief, from 
the large number of cases seen in the Bureau for the Relief of the 
Outdoor Poor, that the arsenical and ferruginous treatment gives more 
satisfaction than any or all other measures. 



528 INFANTILE PARALYSIS. 



CHAPTER XV. 

INFANTILE PARALYSIS. 

Paralysis in young children, especially infants, is in most instances 
due to causes which seldom produce it in adults. The principal cause 
of it in the adult, namely, cerebral apoplexy, is indeed rare in children. 
Paralysis in children has the following recognized causes : 1st. A 
change in the blood, not fully understood, induced by certain grave dis- 
eases, as diphtheria, typhoid fever, measles, scarlet fever, etc. 2d. Re- 
flex influence. The function of some part of the system is in some 
way disturbed, and paralysis occurs in certain muscles, perhaps at a 
distance from the cause, and it disappears when that cause is removed, 
unless it have continued too long. The only rational explanation is 
found in the fact of a continuous connection between the local cause 
and the paralyzed muscles through the afferent and efferent nerves, and 
the nervous centres. 3d. Compression or injury of a nerve-trunk. 
These cases are rare. Pressing of the portio dura by the blades of for- 
ceps during birth, described in the next chapter, is an example. 4th. 
An anatomical alteration in the muscular fibres, the nerves and nervous 
centres remaining unaffected. This has been designated myogenic 
paralysis. This form of paralysis is probably often of a rheumatic 
nature. Paralysis of the face or other portions of the surface, which 
sometimes occurs in children and adults from prolonged exposure to 
cold winds, is of this nature. 5th. Some anatomical change in the 
■nervous centres, as congestion, hemorrhage, inflammation, emboli, 
compression and laceration of brain, whether by tumors, inflammatory 
products, or other causes, etc. If there be hemiplegia the presumption 
is that the disease causing it is cerebral ; if paraplegia, that it is spinal. 
The following is a interesting example of hemiplegia. The case was 
related by me, and the specimen presented to the New York Patho- 
logical Society. 

Case. — Maggie, aged 2 years 8 months, was admitted into the Catholic 
Foundling Asylum about the 1st of September, 1874. She seemed to be 
in good health and was plump and well developed, and her mother stated 
that she had had no serious sickness. After her admission she continued 
well, having the usual appetite, amusing herself through the day, and 
presenting no symptoms to attract attention till December 6th. On the 
evening of December 5th she ate her supper as usual, and was placed m 
her crib, apparently in perfect health. At 3 a. m., the sister who was in 
charge of the ward found her in severe general eclampsia. Immediately, 
in addition to the usual local treatment, she administered five grains of 
bromide of potassium, and this was repeated at intervals till six or seven 
doses were administered. Nevertheless, the spasmodic movements con- 
tinued, with more or less violence, till 1? P. M., and in the muscles of the 
leg somewhat longer. 



case. 529 

On my arrival at the asylum, at about 6 p. m., I found her lying quietly, 
rather stupid, but easily aroused. Her vision was evidently good, and 
she was conscious ; the pupils responded to light, and the direction of the 
eyes was normal ; pulse 104, no cough, and respiration natural ; tempera- 
ture, as ascertained by the thermometer in the axilla, also normal. There 
was no apparent paralysis of the muscles of the face, but the right arm 
and leg were paralyzed, though the paralysis was not complete. The 
great toe flexed on tickling the sole of the foot, but the foot itself had 
little or no motion, and on my attempting to flex the leg, which was ex- 
tended, some rigidity of the muscles was observed. At times the patient 
produced slight movement of the thigh upon the trunk. The muscles of 
the right upper extremity were more flaccid than those of the leg, and 
motion of the forearm was totally lost, while a little movement remained 
of the arm on the trunk. During the two or three days succeeding the 
convulsions sensation in the right limbs did not appear to be entirely lost, 
though greatly enfeebled. Subsequently paralysis in the right limbs, both 
of the nerves of sensation and motion, was nearly or quite total, and 
continued so till death. Nevertheless, tickling the sole of the foot caused 
some movement of the great toe. On the left side sensation and motion 
Avere perfect. 

The record of December 9th runs : Has vomiting to-day for the first 
time ; apparently sees well, and appearance of the eyes normal ; has no 
retraction of head, or rigidity of muscles of neck, or along the spine ; 
pulse 96, temperature in the axilla normal; lies quiet and with eyes shut; 
is stupid, and not fretful when aroused ; the bowels move regularly. 

December 11th, continues to vomit at intervals ; pulse 68. Dec. 16th, 
pulse 80, temperature 100° ; vomited once yesterday, none to-day ; lies in 
a constant doze; takes bromide of •potassium gr. iv three times daily. 
Dec. 18th, moans at times, as if in pain ; pulse 180, temperature 100° ; 
takes the bromide gr. iv every four hours. 

Dec. 19th, pulse 180, temperature 103° ; she has convergent strabismus, 
and the eyes have a wild, almost iusane look, but she sees, grasping hur- 
riedly the percussion hammer presented toward her ; paralysis of nerves 
of motion and sensation in the right extremities nearly complete ; slight 
movement is still produced in the great toe by titillation ; the vomiting 
has ceased ; tongue covered with a thick fur ; movements of the bowels 
pretty regular ; has a slight cough, such as is common in cerebral disease. 

Dec. 22d, lies quietly on her side in perpetual slumber, with eyes con- 
stantly shut ; pulse 118, temperature 101£° ; the bowels still move nearly 
normally ; the pupils, exposed to the light, are seen to oscillate, but are 
constantly more dilated than in health ; the urine passes freely ; circum- 
scribed flushing of the features at intervals ; a rash like lichen over abdo- 
men and chest, possibly due to the large quantity of bromide of potassium 
administered. 24th, pulse intermittent ; pupils dilated. 

Dec. 25th, died in profound stupor to-day, having lived nineteen days 
from the commencement of the malady. 

Autopsy. — About thirty hours after death ; weather cool. On removing 
the calvarium and dura mater, which presented no unusual appearance, 
the vessels of the pia mater were found rather more injected than usual, 
but not more so than we sometimes observe in those who die of diseases 
which do not involve the brain. The cerebro-spinal fluid was scanty, and 
the surface of the brain rather dry. The vertex of the left hemisphere 
was unusually prominent, rising perhaps half an inch higher than that on 
the opposite side. At the highest point, which was about one and a half 

34 



530 INFANTILE PARALYSIS. 

inches from the median line, was a circular yellowish spot upon the sur- 
face of the brain about one and a half inches in diameter. Pressure upon 
this spot, made lightly, so as not to produce rupture, communicated the 
sensation of a large cavity underneath filled with liquid, and approaching 
to within two or three lines of the surface. There was no adhesion or ex- 
udation over this spot; and the surface of the brain appeared entirelv 
normal, except a little cloudiness of the pia mater over a space which 
could be covered by a five-cent piece, a little posterior to the optic com- 
missure. The incised surface of the brain, at a distance from the abscess, 
showed no increase of vascularity. The right hemisphere appeared in 
every way normal, except that its lateral ventricle was filled with pus, but 
not distended. 

On the left side, occupying the centre of the hemisphere, was an abscess 
as large as the fist of a child of two years, extending from within two or 
three lines of the vertex, where its site corresponded with the yellow spot 
on the surface of the brain, to the roof of the lateral ventricle. Through 
this roof the abscess had burst, filling and distending the ventricle with 
pus, and thence making its way into the lateral ventricle of the opposite 
hemisphere. The whole amount of pus contained in the abscess and the 
two ventricles was, perhaps, two ounces. The walls of the left lateral 
ventricle were much softened, the upper part of the corpus striatum and 
thalamus opticus being nearly diffluent ; the walls of the right lateral 
ventricle w T ere slightly softened, but to less depth. The parietes of the 
abscess, which extended from the roof of the ventricle to the vertex, as 
already stated, were indurated to the depth of one and a half lines in con- 
sequence of proliferation of the connective tissue, except at the base of the 
abscess, which corresponded with the roof of the ventricle, where soften- 
ing had occurred. The spinal cord, so far as it could be examined from 
the cranial cavity, had the usual vascularity, and seemed nearly or quite 
normal. 

The cause of encephalitis from which the abscess resulted w T as ob- 
scure. This inflammation, so far as can be ascertained, was idiopathic, 
which is known to be a rare disease. There was no history of otitis, which 
is one of the most frequent causes of cerebral abscess, nor of heart disease, 
so as to produce embolism. It seems probable, since there was no fever 
till about the fourth day after the convulsions, that an abscess had prim- 
arily occurred in the hemisphere between the roof of the ventricle and the 
vertex, probably w r eeks previously. The bursting of this into the lateral 
ventricles and the constitutional disturbance, inflammation, and softening 
to which this gave rise afford sufficient explanation of the history of the 
case after the commencement of the convulsions. 

Paralysis occurring as a symptom or sequel of some obvious local or 
general disease, as diphtheria, lesion of the nervous centres, etc., and 
which may occur at any age, need not detain us. It is described in 
connection with the primary diseases on which it depends. But there 
is a form of paralysis which in the present state of our knowledge we 
must consider an idiopathic malady, and which is peculiar to the first 
years of life, or is so rare at other periods that it is proper to regard it 
as strictly a malady of infancy and early childhood. It occurs between 
the ages of six months and three years. The following description re- 
lates to it : 

Symptoms. — The previous health of the patient is usually good. 
The paralysis does not always commence in the same manner. In a 



SYMPTOMS. 531 

few instances it begins suddenly in the daytime when the child is ap- 
parently in perfect health. In some it begins abruptly, after sound 
sleep. The child goes to bed well, sleeps through the night, and awakens 
in the morning paralyzed. I have known it to occur in one instance 
after sleep in the middle of the day. In these cases there has sometimes 
been an exposure, before the sleep, to wind or rain, or from sitting upon 
a cold stone. In other and the majority of cases the paralysis is pre- 
ceded by a very decided febrile movement, which comes on suddenly, 
without appreciable cause, and after a few days the power of motion is 
found to be lost in one or more of the limbs. No symptom occurs 
during the febrile movement indicative of disease of the brain : conscious- 
ness is retained, and there is no more headache or apparent liability to 
convulsions than is present in other pathological states accompanied by 
an equal amount of fever. The paralysis is at its maximum in the com- 
mencement. Occurring as by a stroke, the full extent of the paralytic 
state is exhibited at once, and so far as there is any subsequent change, 
it is an improvement, as regards the number of muscles affected, and the 
degree of the paralysis. Most frequently the muscles of one or both 
lower extremities are affected. Occasionally one of the upper extremi- 
ties is also paralyzed in addition to the lower, but paralysis of an upper 
extremity is less in degree, and disappears sooner, than that of the lower. 
The bladder and lower bowel remain unaffected, since only the muscles 
of volition are involved. Sensation is unimpaired in the affected limbs, 
and in the commencement there is even in some cases a state of hy- 
peresthesia (West). The febrile movement which precedes and accom- 
panies the paralysis in certain cases, gradually abates, and in a few days 
nothing abnormal remains except the loss of power in the affected mus- 
cles. These muscles are in a flaccid and relaxed state, so that the limb 
falls by its weight when unsupported, and they are usually free from 
pain. The number of muscles paralyzed varies greatly in different cases. 
Only one muscle or a single group of muscles may be affected, or, on 
the other hand, both the extensor and flexor muscles of two or more 
limbs may be paralyzed. In the opinion of Mr. Adams, the following 
table exhibits the groups of muscles and single muscles most frequently 
involved, and in the order stated: 

Gy^oups. 

1. Extensors of toes, and flexors of the foot. 

2. Extensors and supinators of the hand. 

3. Extensors of leg, and with them usually the first group. 

Single Muscles. 

1. Extensor longus digitorum of toes. 

2. Tibialis anticus. 

3. Deltoid. 

4. Sterno-mastoid. 

The following is an example of infantile paralysis, as it not infre- 
quently occurs when the result is favorable: A. K., German, female, 
aged 3 years 4 months, fleshy ; had been in the habit of sitting on the 



532 INFANTILE PARALYSIS. 

ground near the house and on the door-sill. On July 2, 1871, she had 
a sound sleep in the afternoon, having been entirely well previously, 
and awoke trembling and with a high fever at 3 J p.m. At 8 p.m., the 
febrile excitement continuing, general clonic convulsions occurred, last- 
ing about ten minutes. At this time I was called to see her, and found 
her face flushed, surface hot, and pulse about one hundred and thirty. 
Consciousness returned after the convulsion. Her intelligence was good, 
tongue moist and slightly furred, bowels rather constipated, and the 
urine freely passed. The febrile excitement continued two days, when 
it gradually and entirely abated, but before it ceased paralysis of the 
left lower extremity was observed. No weight at first could be sus- 
tained upon this limb, and it hung powerless when we endeavored to 
make her walk. The attempt caused her to cry, as if in pain, and 
pressing upon the thigh, or moving it, had the same effect. The thigh 
of this limb did appear slightly swollen on inspection, but measurement 
did not indicate any notable enlargement. The difference in circum- 
ference was not more than one-eighth to one-fourth of an inch. There 
was no appreciable increase of heat in the thigh over the general 
temperature of the body. Sensibility remained in every part of the 
limb, and the loss of power was not complete, for on the first da}^ as 
soon as the paralysis was observed, slight and imperfect movements 
could be produced by pinching the limb. In three weeks the use of 
the limb was fully restored, by mildly stimulating liniments, and simple 
medicines to regulate the bowels. The tenderness which was observed 
in this case is only occasionally present, and has been attributed to 
hyperesthesia. 

Prognosis — Progress. — The paralysis in nearly all cases soon 
begins to abate. The power of motion returns little by little, and what- 
ever improvement occurs is permanent. There is no retrogression in 
the convalescence. The sooner improvement commences, the more 
favorable is the prognosis. In the most favorable cases there is com- 
plete restoration in from three to four weeks. In other patients, while 
certain of the muscles regain the power of motion, other muscles, oftener 
those of the lower extremity than upper, do not recover their function, 
and, unless proper remedial measures be employed, and even with them 
in certain instances, atrophy soon commences. The temperature of the 
paralyzed limb falls three, five, or even eight degrees, and the amount 
of blood which circulates in it is diminished so that the pulse of the limb 
is feebler and its vessels smaller than in health. With the atrophy the 
contractility of the muscular fibres by the electric current diminishes, 
and in unfavorable cases after a time powerful induced and even primary 
currents have no appreciable effect. The nutrition of a paralyzed limb 
is always imperfect, and if the paralysis occur in a child, its growth is 
retarded. Therefore, in cases of protracted or permanent infantile paral- 
ysis of one limb, a disproportion occurs both in diameter and length 
between it and that on the opposite side. If the paralysis continue, the 
ligaments of the paralyzed limb become relaxed and lengthened. West 
mentions a case of paralysis of the deltoid in which the humero-scapular 
ligaments were so extended that the humerus dropped from the glenoid 
cavity, so as to increase the length of the limb three-fourths of an inch. 



ETIOLOGY. 533. 

In the paralysis of certain muscles of the lower extremity, and contin- 
uance of the contractile power in others, we have the conditions which 
give rise to club-feet, and accordingly this deformity is the common 
result of the paralysis when it is not cured. 

Etiology. — As infantile paralysis is not a fatal malady, opportunity 
for post-mortem examination in a recent case seldom occurs. Hence 
the difficulty in determining the exact anatomical change in the nervous 
system which produces the paralysis. Medical literature contains 
records of a considerable number of cases in which autopsies have been 
made, but death occurred so long after the commencement of the 
paralysis, usually months or years, that it is difficult to determine 
whether lesions which have been observed were a cause or consequence. 
In a majority of these autopsies a spinal lesion of some sort was de- 
tected, but in some instances none could be discovered. 

Mr. Adams, in his treatise on club-foot, relates a case in which the 
spinal cord, carefully examined, probably only with the naked eye, 
seemed normal. Robin examined the spinal cord microscopically in 
one case, but discovered nothing abnormal, and Elischer made autopsies 
in two cases of this paralysis in which death had occurred from variola, 
but with a negative result as regards lesions in the nervous system. 1 The 
examinations by Robin and Elischer, since they were microscopic, have 
been justly regarded as important, and they have been related by writers 
in order to sustain the theory that infantile paralysis is peripheral, and 
not centric. 

Very little was effected, prior to 1863, in determining the cause or 
causes of infantile paralysis by post-mortem examinations, because the 
microscope was so little used, and because in most of the cases reported 
the clinical history or microscopic lesions were such as to show or to 
render it highly probable that the paralysis was not such as is designated 
and understood by the term infantile. Thus Beraud reported a case in 
which tubercles were found in the spinal cord. Hutin, a case in which 
there was atrophy of the lower part of the spinal cord, but the paralysis 
commenced at the age of seven years. Hammond, a case in which a 
clot was found in the spinal cord; and Jaccoud, one of spinal arachnitis, 
with thickening of the meninges. Since 1863, seventeen autopsis have 
been recorded in which the spinal cord was carefully examined, and 
upon these we must chiefly rely for our data by which to determine 
what are the anatomical changes in the nervous system which probably 
cause this paralysis. The reader will find these cases tabulated in a 
lecture by E. C. Seguin, 2 M.D., and the most important of them nar- 
rated in a paper on infantile paralysis, showing great research, published 
by Dr. Mary Putnam Jacobi. 3 It is true that all but three of these 
post-mortem examinations were made many years after the occurrence 
of the paralysis ; but in the three cases which were reported by Roger 
and Damaschino, only two, six, and thirteen months had elapsed. The 
following were the chief lesions observed in these cases as regards the 
spinal cord : 

1 Jahrbuch fur Kinderh., 1873. 

2 N. Y. Med. Eecord, January 15, 1874. 

3 N. Y. Obst. Journ., for May, 1874, 



534 INFANTILE PARALYSIS. 



1. Atrophy of motor-cells in anterior cornua 

2. Nerve-cells, normal 

3. Atrophy (variously recorded) of anterior columns, 

or part of cord, or roots of anterior nerves 

4. Sclerosis 

5. Myelitis, recorded as diffused, central, or slight 

6. Central softening (the three most recent cases) . 

7. Small clot in cord (Hammond's case) 

8. Sciatic neuritis 



or cornua 



10 
2 



It is seen that the most common lesions in these cases were those of 
inflammation of the spinal cord, or such as are known to result from 
this inflammation, to wit, atrophy of the nervous substance and sclerosis. 

With the data furnished by these post-mortem examinations and the 
clinical histories of cases, we are the better prepared to consider the 
theories regarding the etiology of this malady. The views of MM. 
Roger and Damaschino are entitled to great consideration, since the 
autopsies which they made were in cases of shorter duration, and there- 
fore nearer the date of the commencement of the paralysis than those 
which have been reported by other observers. Roger and Damaschino 1 
published a series of papers on this malady, which they conclude with 
the following propositions: " 1. The alteration peculiar to infantile 
paralysis is a lesion of the spinal marrow, which causes the atrophy of 
muscles and nerves. 2. The seat of this lesion is the anterior part of 
the gray substance of the medulla, where softened portions of spinal 
substance are seen. 3. This softening is of an inflammatory nature — 
in fact, a simple myelitis. 4. Infantile paralysis should, therefore, be 
called spinal paralysis of children, and be classed among the affections 
of the spinal marrow, as depending on myelitis." 

To determine the exact character and limitations of the cause of 
infantile paralysis is difficult ; but the views of Roger and Damaschino, 
as expressed in the above propositions, seem to harmonize more closely 
with, and to afford a more satisfactory explanation of, the symptoms, 
history, and lesions, thus far observed in ordinary or typical cases, than 
does any other theory. Many neuropathists regard suddenly occurring 
active congestion of the anterior cornua as the cause of infantile 
paralysis ; but there is that close affinity between active congestion and 
inflammation that they may be regarded as having the same pathological 
effect in this instance, and therefore the two theories of a spinal conges- 
tion and spinal inflammation may be considered as one. It is not 
improbable that in some of the cases which more speedily recover there 
is simple congestion ; while in the more obstinate cases, and those with 
inflammatory symptoms, the congestion has passed into an inflamma- 
tion, or inflammation was present from the first. According to this 
theory, the atrophy so generally observed in the twelve cases in which 
autopsies were made, must be considered a degenerative change result- 
ing from the inflammation or from the paralysis. That so accurate an 
observer and so excellent a microscopist as Robin could detect nothing 
abnormal in the case which he examined, was probably due to the fact 
that the inflammation or congestion abated without producing any 
degenerative changes in the nervous substance. 

1 Gaz. MSd. de Paris, 1871. 



ETIOLOGY. 535 

Professor Charcot considers atrophy of the motor cells as the cause 
of the paralysis, but it is much more in consonance with the facts to 
consider the cellular atrophy a result than a cause. For how could 
atrophv, which always occurs gradually, and by progressive increase, 
be the cause of a disease which begins abruptly, and is most intense in 
the very commencement ? Besides, atrophy does not occur without 
some antecedent disease to cause it. 

In a report to the International Congress at Amsterdam, Drs. Da- 
maschino and Roger give the following summary of the result of their 
recent study of the pathology of infantile paralysis : T 

1. The anatomical lesions are situated in the motor regions of the 
spinal cord. 

2. They consist of a central myelitis, with a stadium of softening, 
and atrophic destruction of the cells of the gray substance, together with 
sclerosis of the lateral columns, and considerable atrophy of the anterior 
roots and the nerves leading to the paralyzed muscles. 

3. Atrophy of the cells is not — as Charcot is of opinion — the whole 
process, as it is in progressive muscular atrophy. 

4. The opinion of Leyden, that there is a circumscribed and a dhTuse 
myelitis in children, is worthy of consideration. 

5. It remains for future examination to decide whether the myelitis 
begins as interstitial or parenchymatous, in the cellular tissue or the 
nerve-cells. 

It would be a waste of time to consider in full the various theories 
regarding the cause of infantile paralysis. No one at the present time, 
of those who are competent to express an opinion, believes it to be a 
reflex paralysis, and the expression dental paralysis once applied to it 
is no longer heard. There is one theory, however, which should 
receive more than a passing notice, and which was earnestly and ably 
advocated by Barwell, 2 of London, in lectures published by him in 
1872, to wit: "That this paralysis is purely peripheral; a malady 
affecting the ultimate fibrillge of distribution of the nerves amono- the 
muscular elements. ... Its essence," says he, "lies probably in 
some subtile derangement in relationship between the ultimate muscular 
and terminal nerve fibres, perhaps from some inflammatory, perhaps 
from some chemical or nutrient change." This theory has much to 
commend it. Those who advocate it believe that the atrophy of the 
nerves which supply the paralyzed limbs and of the motor nerve-cells 
which connect with the roots of these nerves in the anterior cornua 
occurs in consequence of the paralysis, just as atrophy of the optic nerve 
can be traced even into the brain when the eye is destroyed. Nor does 
it dispose of this theory to state, as has been stated, that in order that 
paralysis may occur in this manner, it is necessary that there should be 
the action of a poison, analogous to woorari, for we observe something 
similar to this supposed peripheral cause in facial paralysis from exposure 
to cold, in which there can be no poisonous influence. This theory 
therefore rises up most strongly in conflict with that which attributes 
the paralysis to congestion or inflammation of the anterior cornua, and 

1 Le Progres Medical, No. 39, 1880. 2 London Lancet, 1872. 



OoO* INFANTILE PARALYSIS. 

it is necessary to decide between them, or to admit that the paralysis 
may sometimes have one and sometimes the other cause. But the fact 
that there is in many cases of infantile paralysis a decided febrile move- 
ment and much constitutional disturbance, when there is no evidence of 
any morbid action going forward in the affected limbs sufficient to cause 
these symptoms, and the fact that only one set of nerves is affected, 
to wit, the motor, which have a distinct origin in the spine from the 
sensitive nerves, but are intimately associated with them in their distri- 
bution, comport best with the theory of a central lesion. Therefore, 
the theory of spinal congestion or inflammation appears the best estab- 
lished. Nevertheless, past experience shows that medical theorizers are 
liable to be too exclusive, and that in many diseases the causes are not 
uniform, but they vary in different cases, especially when, as in the 
present instance, the symptoms also vary. Possibly, therefore, there 
may be cases of paralysis of the extremities in children, especially those 
in which there is little constitutional disturbance and a known exposure 
to cold, in which the cause is peripheral instead of centric. The brain 
and cerebral meninges may be excluded as sustaining any causative 
relation to the paralysis. There is no symptom which indicates that they 
are involved. The mind remains clear, and convulsions are no more 
frequent than in any other disease which is attended by an equal degree 
of febrile movement. 

Anatomical Characters. — All muscular fibres which are in a state 
of disuse, begin in a few weeks to atrophy, and undergo fatty degenera- 
tion. The transverse striae in the primitive muscular fasciculus gradu- 
ally disappear and . are replaced by granules of fat, and later still by 
small oil-globules. If we examine with the microscope the fibres from 
a muscle which has been a considerable time paralyzed, but which has 
still some electric contractility, we will find in places the striae remain- 
ing, but numerous opaque granules of a fatty nature within the sarco- 
lemma wherever the striae are absent, and in other places, where the 
degeneration is most advanced, oil-globules occur, always small. If the 
paralysis be more profound, the striae have all disappeared. At a later 
stage, usually after some years in cases of complete and incurable paral- 
ysis, the fatty matter may be to a considerable extent absorbed, and 
the fibrous network of the muscle which remains presents a tendinous 
appearance. There is a great difference, however, in different cases, as 
regards the rapidity with which these changes occur. Hammond states 
that he found the striae remaining in two cases after the lapse of more 
than four years of decided paralysis. The nerves of the paralyzed part 
also undergo atrophy. 

Diagnosis. — This is easy as soon as the attention of the physician is 
directed to the state of the limbs. In a large proportion of cases the 
mother or nurse first observes the paralysis, and calls the attention of 
the physician to it. A knowledge and recollection of the facts in rela- 
tion to infantile paralysis should lead the physician to examine the state 
of the limbs in all cases of marked febrile excitement in young children, 
occurring without apparent cause. 

Prognosis. — It may be confidently predicted, if the child be seen 
early, and correctly treated, that the paralysis will diminish, if it can- 



TREATMENT. 537 

not be entirely cured. If the paralysis have continued a considerable 
time, and there be no electric contractility of the muscles, there is poor 
prospect of any improvement. The induced current will fail, sometimes, 
to cause muscular contraction, when the direct current may produce it ; 
but if there be no response to the direct current, there is no therapeutic 
agent which can restore the use of the limb. 

In cases seen soon after the paralysis commences, and before the stage 
of atrophy, the prognosis is most favorable, when there is still slight 
voluntary motion, and improvement commences early. In most in- 
stances, even when the paralysis has been mild, and of comparatively 
short duration, the limb, although its motion be fully restored, is for a 
long time weaker than the limb on the opposite side. 

TREATMENT. — A physician called at the commencement of the paral- 
ysis should endeavor to remove every cause which might increase the 
irritability of the nervous system. Some advise to scarify the gums, if 
much swollen and tender from dentition, the bowels should be kept 
regular, worms, if present, expelled by appropriate medicines, and the 
diet be plain and unirritating. Since the cause of the paralysis is, in 
the commencement, still operative, measures are appropriate which are 
calculated to remove it. 

Local treatment is very important at all periods of the paralysis. In 
the first days cold applications, as by an India-rubber bag containing ice, 
should be made over the spine. Stimulating embrocations over the 
spine, and upon the paralyzed limb, are appropriate after the cold has 
been discontinued, and benefit may also be derived from dry cups along 
the spine. Ergot, the bromide and iodide of potassium, which may be 
administered variously combined, or singly, are the appropriate remedies 
for the first twelve or fourteen days. Administered every three or four 
hours in proper dose, they are the most effectual of all internal remedies 
for diminishing spinal congestion, and preventing effusion, and perma- 
nent structural change in the cord. Unfortunately this first stage is in 
many instances far advanced before proper treatment is employed to 
subdue the myelitis, either from an incorrect diagnosis, or because the 
plrysician is not summoned until structural changes have occurred, 
which constitute the second stage. 

If the paralysis continue, or if it do not progressively diminish, we 
should not delay more than two weeks from the commencement of the 
disease before employing appropriate measures to restore the use of the 
limbs, and arrest atrophy of the muscles. The expectant plan of treat- 
ment which is proper in many diseases of children is unsuited to this. 
Muscular atrophy may commence in three weeks, and the further it has 
advanced, the more difficult and tedious will be the cure. Therefore, 
by the close of the second week if the paralysis continue, or be not 
rapidly disappearing, iron as a tonic with strychnia should be pre- 
scribed. There is probably no better formula for the exhibition of 
these agents than the following from Professor Hammond : 

R. — Strych. sulphat. . . . . . . gr. j. 

Ferri pyrophosphate . . . . . gss. 

Acidi phosphorici dilut. . . . . 5ss. 

Syr. zingib 5iij ss - — Misce- 



538 FACIAL PARALYSIS. 

One-third of a teaspoonful, or one-ninetieth of a grain of strychnia, 
is sufficient for a child of two years, administered three times daily. 
Hillier, Barwell, and others have employed subcutaneous injections of 
strychnia, with, it is stated, a good result. While in the first and 
second weeks the child has been allowed to remain quiet, he should now 
be encouraged to use his limbs. Frequent muscular contraction must, 
if possible, be produced, and the voluntary movements, w T hen not totally 
lost, aid greatly in promoting the nutrition of the muscles and restoring 
their function. Immersing the limb for half an hour in water at a tem- 
perature of 110 or 115 degrees, rubbing the limb with a coarse towel, 
and kneading the muscles, aid also in restoring nutrition and tone to 
them. 

But, fortunately, we have an invaluable agent in the subtle electrical 
fluid, which can be made to penetrate the muscles and cause their con- 
traction w T hen every other measure has failed. The induced current 
should be employed upon the limb every day, or second day, if it cause 
the muscles to act, but if the loss of pow T er be of long standing, or com- 
plete, so that the induced current is not sufficiently powerful, the direct 
current should be used instead. It is not regarded as important which 
way the current passes, provided that the muscles contract. 

In a large proportion of cases a cure cannot be effected until the 
lapse of several months, so that the patience of the physician and 
friends may be put to the test ; but if muscular atrophy can be pre- 
vented, and the limb kept at nearly the normal temperature, this mode 
of treatment will ordinarily in the end be successful. The primary affec- 
tion which caused the paralysis will, with some exceptions, be removed 
by the treatment indicated above, after which the state of the muscles 
and their nervous supply demand the whole attention. Observations 
show that by treatment perseveringly employed, fatty degeneration of 
the muscular fibres can be not only arrested, but the fat which has 
already been deposited within the sarcolemma may be absorbed, and the 
muscular striae restored. In those cases in which it has been necessary 
to employ the direct current, the induced should be used, whenever by 
the improvement of the case it is found sufficiently powerful. 



CHAPTEE XYI. 

FACIAL PAEALYSIS. 

Causes. — Facial paralysis, in the newborn, commonly occurs from 
pressure of the blade of the forceps upon the portio dura, at a point 
external to the stylo-mastoid foramen. It may also occur in children of 
any age, from exposure of the face to a cold wind. The pressure of a 
tumor upon some part of the portio dura, or even of the fist of the child 



TREATMENT. 539 

placed under the face during sleep, may cause it. It may also result 
from disease of the temporal bone, producing pressure on the nerve, 
as caries, periostitis, suppuration, or hemorrhage into the aquseductus 
Fallopii, and also from intracranial disease affecting the pons Varolii 
or the medulla oblongata. 

Symptoms. — The portio dura, which is a nerve of motion, supplies 
the muscles of the face, and therefore its loss of function is at once mani- 
fest in distortion of the features. The eye of the affected side remains 
open in consequence of paralysis of the orbicularis palpebrarum, the 
upper lid being raised by the levator muscle, which is not paralyzed, since 
its nerve is derived from the third pair. From the inability to wink, 
the eye becomes irritated by dust and constant exposure, and, in chil- 
dren old enough to have an abundant lachrymal secretion, the tears are 
liable to flow over the cheek. On account of the paralyzed and relaxed 
state of the facial muscles the mouth is drawn toward the healthy side, 
while the affected side presents a swollen appearance. Movement of the 
eyebrow of the anterior portion of the scalp on the paralyzed side is also 
impossible, since the occipito-frontalis and corrugator supercilii are sup- 
plied by the portio dura. If the cause of the disease be located above 
the origin of the chorda tympani, the flow of saliva and sense of taste 
on the affected side are impaired. If the injury be posterior to the 
gangliform enlargement, those symptoms are superadded which are due 
to paralysis of the petrosal nerves. 

The accompanying woodcut represents a case which was under obser- 
vation in the New York Infant Asylum. Its age at admission was 
about five months, and its previous history was unknown. The paral- 
ysis was permanent. Death occurred some months later from an inter- 
current disease, and no cause of the paralysis could be discovered in a 
careful examination. 

Prognosis. — This depends on the cause. If the cause be periph- 
eral, as from the pressure of the forceps or from cold, the prognosis 
is favorable. In cases of deep-seated le- 
sion, unless syphilitic, the prognosis is Fig. 31. 
usually unfavorable. A syphilitic lesion 
can often be removed by appropriate 
remedies, and the paralysis cured. 

Treatment. — In the paralysis of the 
newborn, from pressure of the forceps, 
all that is required is occasional rubbing 
or gentle kneading over the affected 
muscles. In those who are older, the 
nature of the cause, so far as ascertained, 
must determine the treatment. If there 
be glandular swellings, and discharge 
from the ear from scrofula, cod-liver oil 
and the syrup of the iodide of iron are 

required internally, with appropriate external treatment of the glands 
and ear. If syphilis be the cause, mercurials and the iodide of potas- 
sium should be employed. If the patient do not soon begin to im- 
prove, the treatment recommended for infantile paralysis, modified 




540 PARALYSIS WITH PSEUDO - HYPERTROPHY. 

somewhat on account of the difference in location, is appropriate. Iron 
and strychnia may be administered internally. The external treatment 
should consist of friction, kneading, hot applications, and the electric 
current. The current should have only moderate intensity, for a high 
degree of it might injure the vision. It should be applied every second 
day, with one pole over the mastoid foramen, and the other moved slowly 
over the muscles. 



Paralysis with Pseudo-Hypertrophy. 

This is a rare disease. It was first described by Duchenne in 1861, 
and since the attention of the profession was directed to it, cases have 
been observed on the Continent, in Great Britain, and in this country. 
Though our acquaintance with it is so recent, it has been fully and ac- 
curately described by various writers in our language. The Trans- 
actions of the London Pathological Society for 1868, contain a trans- 
lated paper relating to it, communicated by M. Duchenne, with photo- 
graphic views and remarks by Lockhart Clarke, and also the histories 
of two cases occurring in London, and exhibited to the Society by Adams 
and Hillier. In this country an elaborate paper has appeared on this 
form of paralysis, from the pen of Dr. Webber, 1 of Boston, who suc- 
ceeded in collecting the records of forty-one cases ; and more recently 
Dr. Poore, 2 physician to the New York Charity Hospital, collated the 
records of eighty -five cases, which furnish the material of an excellent 
monograph. 

Weakness of the legs, and a peculiar waddling gait, are the first ob- 
servable symptoms, and by them we are able to ascertain approximately 
the date of the commencement of the paralysis. In 27 of the cases col- 
lated by Dr. Poore, the malady began so early in infancy that they 
were never able to walk like other children ; in 5 there is no record in 
regard to the time when the peculiar gait was first observed, or whether 
they ever could walk. Fifty-two, or about two-thirds of the cases, 
walked well at first, having no symptoms of the paralysis till after the 
age of two years. In 15 of these, weakness of the legs and the peculiar 
gait were first observed between the ages of two and a half and five 
years ; in 23 between the ages of five and ten years*; in 6 between the 
ages of ten and sixteen years, and in 8 over the age of sixteen years. 
It is seen, therefore, that this malady is preeminently one of infancy 
and childhood. 

The gait, which is unsteady and waddling, has been compared to that 
of a duck. The child stands with the legs wide apart, and from the 
weakness of the legs, and unsteadiness of the gait, frequently stumbles 
and falls. In many cases this muscular weakness and difficulty in 
walking occur before there is any perceptible enlargement of the mus- 
cles beyond the normal size. 

The hypertrophy occurs without tenderness, pain, or other nervous 
symptoms, and without fever or constitutional disturbance. Occasion- 

1 Boston Med. and Surg-. Journ., Nov. 17, 1870. 

2 New York Medical journal for June. 1875. 



PARALYSIS WITH PSEUDO -HYPERTROPHY 



541 



Fig. 32. 



ally the patient complains of stiffness or aching in the limbs, especially 
after exercise, even before the enlargement is observed, and exception- 
ally there is pain, even acute, in the legs. The hypertrophy is ordi- 
narily observed first in the calf of one leg, and then in the opposite calf. 
In a case related by Niemeyer, the muscles of the gluteal region were first 
affected. In nearly all cases the gastrocnemii are hypertrophied. There 
were only two exceptions in the 85 cases collated by Dr. Poore ; but 
almost any of the other muscles, or groups of muscles, may also be in- 
volved. The muscles which are most prominently affected, and which 
produce the characteristic deformities, are those of the extremities and 
posterior aspect of the trunk. Spinal curvature, which is attributed to 
the weakened state of the erector muscles of the spine, appears early, 
and is seldom absent. The bending is such that a plumb-line, falling 
from the most posterior of the spinous processes, falls behind the plane 
of the sacrum, which is a means of distinguishing this disease from cer- 
tain other spinal affections. The woodcut represents a case which came 
to the children's class at Bellevue, in April, 1872. The boy was two 
years old, and the mother stated that the peculiar gait and the enlarge- 
ments had only been observed from four to six weeks, and yet the curva- 
ture of the spine was quite marked. He did not return to the class, and 
his subsequent history is therefore unknown. 

Of the muscles in the upper extremities the deltoid and scapular are 
the most frequently enlarged. Hypertrophy of the temporals has been 
observed in three cases, of the masseters in 
two, of the tongue in three, and of the heart 
in four (Poore). 

We shall see presently that atrophy oc- 
curs in the muscular element of the parts 
which are affected, and that the hypertrophy 
is due to hyperplasia of the connective tissue. 
"Now occasionally this hyperplasia does not 
occur or is tardy in occurring, while the 
atrophy has taken place. Therefore, certain 
muscles may have less than the normal vol- 
ume, which, from contrast with those which 
are hypertrophied, increases the deformed 
appearance. In ordinary cases the enlarge- 
ment advances more rapidly and continues 
greater in the gastrocnemii, which are, as we 
have stated, the muscles first affected, than 
in other muscles, and therefore there are more 
prominence and hardness of the calves of the 
legs than elsewhere. In advanced cases walk- 
ing is impossible, and the patient is obliged 

to remain in a reclining posture. Sometimes from the unequal muscular 
action the feet become extended and the toes flexed, so that the child, in 
attempting to walk, steps on the anterior part of the sole of the foot, as 
in talipes equinus. 

In the first stages of the disease the electric contractility of the mus- 
cles is nearly normal, but in advanced cases response to the galvanic 




542 PARALYSIS WITH PSEUDO -H YPERTROP H Y . 

current becomes more and more feeble, according to the degree of 
atrophy of the muscular fibres. The skin retains its normal sensibility, 
with exceptional instances in which there is numbness either general or 
in places. Reddish or bluish mottling of the surface of the extremities 
is sometimes observed, which is attributed by some to obstructed venous 
circulation in the hypertrophied muscles, and by others is supposed to 
be due to the peculiar neuropathic state. The bladder and rectum are 
not involved. The mental faculties are more or less blunted and feeble 
in certain cases, especially in those which commence in early infancy, 
but in some patients they do not seem to be materially impaired. 

Anatomical Characters. — There have been so few post-mortem 
examinations of those who died having this disease, that it is still uncer- 
tain whether there is any centric lesion. Cohnheim examined the spinal 
cord in one case, and could find nothing abnormal. Recently, Mr. 
Kesteven has examined the brain and spinal cord from a case, and found 
dilatation of the perivascular canals, both in the brain and spinal cord, 
and also spots of granular degeneration chiefly in the white substance, 
"caused by loss of cerebral tissue replaced by morbid matter." 1 As 
this child was imbecile, it is not improbable that these lesions were con- 
nected with the mental state, and not the muscular disease. 

Professor Charcot 2 reports a careful microscopic examination of the 
spinal cord and of the nerves in a case which had continued ten years. 
He could discover no deviation from the healthy state. More recently 
Dr. J. Lockhart Clarke 3 examined a case and found the encephalon 
healthy, but in the spinal cord there was more or less disintegration of 
the gray substance in each lateral half, and in places dilatation of 
vessels, and commencing sclerosis. 

It seems, therefore, that central lesions are not essential, and are 
sometimes absent. When they do occur, it is probable that they are 
consecutive to the paralysis. 

The essential lesions in this malady are atrophy of muscular fibres 
and hyperplasia of the connective tissue which surrounds these fibres. 
The hyperplasia of the one element in the muscle is greater than the 
atrophy of the other, and hence the increase of volume above the normal 
size. The atrophy is probably a primary lesion, for muscular weakness 
ordinarily occurs for a considerable time before there is any evidence of 
the enlargement, and, as we have seen, certain muscles may undergo 
the atrophy without the hyperplasia. Still the mechanical effect of the 
newly formed connective tissue, doubtless, increases the atrophy in those 
muscular fibres which this tissue surrounds, and the comparatively quiet 
state of muscles in consequence of paralysis not only tends to promote 
the atrophy and degeneration of these muscles, but also of contiguous 
healthy muscles. 

The muscles which are involved in this paralysis present a pale yel- 
lowish hue, resembling, says Niemeyer, the appearance of lipoma. Ex- 
amining by the microscope, we find in addition to a large increase in 
the fibrous tissue and atrophy, and in some places disappearance of the 

1 Jour, of Med. Sci., Jan. 1871. 

2 Archiv. de Physiol., March, 1872. 

3 Medico-Chir. Trans., 1874. 



TREATMENT. 543 

muscular element, more or less fatty matter, granular and globular, oc- 
cupying the interstices. Mr. Kesteven describes as follows the appear- 
ance of the muscles in the case which he examined: "The muscular 
substance is pale, almost white, and very greasy. The superabundance 
of fat is evident to the naked eye. The muscular fibres present the 
ordinary striation, but less distinctly than usual. The ultimate fibres 
are pale, and separated by a large increase of areolar and fibrous tissue." 

Causes. — Why there is this strange perversion of nutrition, so that 
there is an exaggerated development of the connective tissue of the 
muscles and atrophy of the muscular fibres, is unknown. Boys are 
more liable to be affected than girls. Of the eighty-five cases embraced 
in the statistics of Dr. Poore, seventy-three were boys, and there was a 
similar excess of males in the cases collated by Dr. Webber. 

There is in a considerable proportion of cases the record of heredi- 
tary transmission, and in almost all the instances the predisposition is 
acquired from the mother's side. Thus in thirty-seven of Dr. Poore's 
cases "two or more belonged to the same family. " In some instances 
three and even four maternal relatives had this form of paralysis. In 
one case observed by Duchenne, and in a few others subsequently ob- 
served, this malady seemed to be congenital, for the limbs at birth were 
unusually large, and the patients, when they came under observation, 
were unable to walk. No relation has been observed between this 
paralysis and syphilis, scrofula, or other diathesic diseases. 

Prognosis. — This disease is in most instances progressive, termi- 
nating fatally after a variable period. It is in its nature chronic, rarely 
ending in less than five or six years. A considerable proportion live 
longer, some even attaining adult age. The paralysis may be stationary 
for a time, but afterward continue to increase. Duchenne has reported 
one case of recovery. In two or three other instances patients ap- 
peared to improve somewhat under treatment, but the writers admit 
they may have become worse afterward. Death usually occurs, not 
directly from the paralysis, but from some intercurrent disease, especi- 
ally of the lungs. 

Treatment. — The treatment thus far employed has been chiefly 
local, consisting in the use of electricity, and kneading or shampooing 
over the affected muscles. Both the primary and induced electrical 
currents have been employed, but, unfortunately, without any appre- 
ciable benefit in most cases. Benedikt, who claims a better result from 
electrization than any other observer, applied the copper pole over the 
lower cervical ganglion, and the zinc pole along the side of the lumbar 
vertebrae by means of a broad metallic plate. 



54-i DISEASES OF SPINAL CORD, ETC. 



CHAPTEE XVII. 

DISEASES OF THE SPINAL COED AND ITS COVERINGS. 

The diseases of the spinal cord, and of the parts which cover and 
protect it, are important, but they are less understood than are those 
of any other portions of the body. This is partly due to the fact, that 
in many cases the spinal disease coexists with a similar pathological 
state of the brain or its meninges, the symptoms of which predominate 
and mask those which pertain to the spine, partly to the fact that the 
chief symptoms of spinal disease are often located in organs or parts 
which are at a distance from the spine, and, lastly, to the fact that it is 
difficult, for obvious physical reasons, to determine the exact state of the 
spine at the bedside ; while post-mortem inspection of the spine, which 
alone can give accurate pathological knowledge, is less frequently made 
than of any other organ. 

Certain spinal diseases occurring in childhood are the same as in 
adult life, presenting identical symptoms and lesions in the two periods, 
and therefore they require no extended notice in this treatise. Others 
are common to childhood and maturity, but they present peculiarities 
in the former period which require to be pointed out, while others still 
are peculiar to childhood. 

Spinal irritation is not infrequent in delicate and poorly fed children. 
I have from time to time observed marked cases of it in the class in the 
Outdoor Department of Bellevue, the patients usually being above the 
age of three or four years, and exhibiting evidences of cachexia. Most 
of them have been spare and pallid, some affected with a nervous 
cough or palpitation, and some with neuralgic pains in the chest, abdo- 
men, or elsewhere, which pressure at a certain point upon the spine 
intensified. These cases recover by better feeding, outdoor exercise, 
mild counter-irritation along the spine, and the use of tonics, especially 
of iron. 

Primary inflammation of the cord and its meninges is rare in chil- 
dren. Secondary inflammation of these parts is, on the other hand, 
more common in children than in adults. It is common in caries of 
the vertebrae, and in cerebro-spinal fever. The preponderance in func- 
tional activity of the spinal cord, and the feeble controlling power of 
the brain, render childhood more liable to convulsions and reflex paral- 
ysis than any other period of life. Until within a recent period, most 
cases of infantile paralysis were believed to be reflex, due to dentition, 
intestinal irritation, etc., but it is now attributed to myelitis in the 
motor region of the spinal cord (see remarks in article, Infantile Paral- 
ysis). Still there are cases of true reflex paralysis in children, in regard 
to the etiology of which there can be no doubt. Prof. Sayre, of this 
city, has called attention to the fact, that balanitis and preputial adhe- 



CONGESTION OF SPINAL CORD, ETC. 545 

sions sometimes cause paraplegia, more or less pronounced, in young 
children, and which is relieved by dividing the adhesions, and restoring 
the mucous surface of the glans and prepuce to its normal state. Such 
a case was brought to the children's class in the Outdoor Department 
at Bellevue, in April, 18T5. The child could not walk, or scarcely 
stand, without support, but after the division of the adhesions, and sub- 
sidence of the inflammation, locomotion rapidly improved. 1 It is well 
known that masturbation sometimes causes a similar weakness of the- 
lower extremities. Dr. West relates the case of a child " between two 
and three years old," who began to totter in his gait, and finally almost 
ceased walking. He was observed to practise masturbation. " This 
was put a stop to," and he soon recovered his health and his power of 
locomotion. 2 



Congestion of the Spinal Cord and its Membrane. 

Congestion of the spinal cord and meninges occurs both as a primary 
and secondary malady, the latter being more frequent than the former. 
It may be active or passive. Active congestion, occurring indepen- 
dently of meningitis or myelitis, is in most instances transient, and sub- 
ordinate to some graver disease, in the course of which it arises. It is 
probably often overlooked. It is not fatal, and its symptoms are fre- 
quently masked by those which are referable to the brain or some other 
organ. It is believed to be common in the initial period of certain of the 
fevers of childhood. It is not improbable that the hyperesthesia ob- 
served upon the thoracic and abdominal surfaces and along the thighs, 
in the commencement of remittent and certain other febrile diseases, 
has its origin in a congested state of the spine. To this congestion 
writers attribute the lumbar pain and occasional paraplegia in the initial 
stage of variola. Active spinal congestion may also result from the 
sudden impression of cold, and to it, as has been stated above, most 
neuropathists attribute the so-called infantile paralysis or poliomyelitis 
acuta. 

Certain anatomical circumstances favor the occurrence of passive con- 
gestion of the spinal cord and meninges, to wit, the tortuousness of their 
veins, and the absence of valves in these veins, the lack of muscular 
support of the vessels, and the inferior position of the spine in sickness 
as the patient lies quietly in bed. A common cause of passive conges- 
tion of these parts is some protracted and enfeebling disease, which 
diminishes the contractile force of the heart (cardiac paresis), producing 
congestion of the spinal cord in the same manner as under similar cir- 
cumstances hypostatic congestion of the lungs occurs. Severe convul- 
sive diseases, as tetanus or eclampsia, when protracted or occurring at 
short intervals, commonly produce spinal congestion. In tetanus, this 

1 Some months since I requested Drs. Holgate and Bosky, attending physicians 
in the children's class at Bellevue, to make examination of the state of the prepuce 
in infancy. They report that they have found preputial adhesions almost daily, in 
most instances without sj-mptoms, but sometimes with dysuria, and only in rare 
instances with paralysis. 

2 Diseases of Children, page 146, 4th American edition. 

35 



0±6 CONGESTION OF SPINAL COED, ETC. 

congestion is extreme, so that extravasation of blood is liable to occur 
from the engorged vessels, especially those of the pia mater. 

Anatomical Characters. — It is often impossible, at post-mortem 
examinations, to determine how much of the congestion of the spine and 
its meninges is pathological, and how much cadaveric ; since, if the 
corpse be placed on its back at death, a very considerable engorgement 
of the spinal vessels occurs from gravitation of blood. If the body have 
been placed on the side or face, this cadaveric congestion is prevented. 
Since, in active congestion, the arterioles and capillaries are distended 
with arterial blood, the color is a brighter red than in passive conges- 
tion, in which venous blood predominates. Active congestion of the 
cord usually coexists with that of the meninges, but it may occur with- 
out it. In cases of considerable congestion, the " puncta vasculosa " 
appear upon the incised surface, both of the white and gray substance. 
If the congestion be protracted, or if it recur frequently, it may produce 
permanent dilatation of the arterioles and capillaries, in greater or less 
degree, and it may also lead to sclerosis of the cord. Passive conges- 
tion seldom, perhaps never, occurs in the cord, without being equally 
and often to a greater extent present in the meninges. Continuing for 
a time it gives rise to transudation of serum into the interspaces over 
the cord, and even softening of the cord may occur to a limited extent 
from imbibition of serum. In either form of congestion, extravasations 
of blood are frequent. 

Symptoms. — Spinal congestion is announced by pain in the region 
of the spine, usually in the lumbar, or dorsal and lumbar portions, and 
irradiations of pain, and tingling in the legs. In addition, more or less 
paralysis of the bladder and legs may result. The paraplegia may 
occur early or not till the lapse of several days. In active congestion, 
the symptoms are rapidly developed, and they attain their maximum 
intensity sooner than in the passive form. In passive congestion the 
development of symptoms is not only more gradual, but they are ordi- 
narily less pronounced, and are attended by more fluctuation than in 
the active form. The paralysis, if present, comes on slowly after 
several days and is incomplete. Spinal congestion, especially of the 
passive form, is sometimes associated with cerebral congestion, as for ex- 
ample in tetanus and severe eclampsia, and the spinal symptoms there- 
fore coexist with those which have a cerebral origim The duration and 
the result of a hyperseuiic state of the spinal cord and its meninges, 
depend largely on the nature of the cause. If it be not relieved within 
a few days there is strong probability that some other serious patho- 
logical state has supervened, as meningitis, myelitis, extravasation of 
blood, or serous transudation, with softening of the nervous substance. 

Treatment. — In the adult, spinal congestion sometimes results from 
the sudden cessation of the hemorrhoidal or catamenial flow, and the 
application of leeches or wet cups along the spine is indicated. But in 
the child, the abstraction of blood is seldom required. In the acute 
stage of active spinal congestion, with decided febrile movement, cold 
applications along the spine are often beneficial, as by an India-rubber 

In active hyperemia, laxatives are useful, and rubefacient applica- 



SPINA BIFIDA. 547 

tions should be made along the spine, as by mustard, or by friction with 
a stimulating liniment. In the inflammatory spinal congestion of cere- 
brospinal fever, I have employed with a very satisfactory result a lini- 
ment containing equal parts of camphorated oil and turpentine. In 
both active and passive hyperemia lateral decubitus should be pre- 
scribed rather than dorsal. The use of ergot, in order to diminish the 
turgescence of the vessels of the spinal cord and meninges, has been ad- 
vocated by Brown-Sequard, and it is now one of the recognized reme- 
dies. Bromide of potassium is also a remedy of value, but it is more 
useful in certain cases than in others. It is signally beneficial in those 
cases in which there is also cerebral congestion. When the congestion 
is increased or produced by clonic convulsions, the bromide is one of 
the most reliable remedies which we possess for the removal of the cause. 
Thus it should be employed in the treatment of the spinal and cerebral 
congestion in the commencement of variola, in which convulsions are 
so common, and in the convulsions of pertussis, which cause extreme 
passive congestion of the cerebro-spinal axis. Passive congestion of the 
spine, common in exhausting diseases, and due to feebleness of the cir- 
culation, is best treated by stimulating and sustaining remedies, and by 
the lateral decubitus. It is hypostatic, and may be associated with a 
similar congestion in the posterior part of the lungs. 



CHAPTEE XVIII. 

SPINA BIFIDA. 

This is one of the most common of the malformations. In its severe 
form it is from its nature incurable, admitting only of palliative treat- 
ment, while in its milder forms it may be cured, or so relieved as not 
to compromise life. The term spina bifida is applied to a hernia of the 
spinal meninges, which produces a rounded tumor, situated posteriorly 
over the spine in the median line. It is due to the congenital absence 
or incompleteness of one or more of the arches of the vertebrae. In ex- 
ceptional instances, the arch is said to be complete at birth ; but the 
lateral portions separate, and are pressed outward during the first weeks 
of life. The tumor contains the cerebro-spinal fluid, and unless it be 
small, and its walls unusually thick, fluctuation may be detected in it. 
When the child cries the tumor enlarges, and it is reduced by compres- 
sion, the fluid reentering the spinal canal. If the tumor be large, its 
complete subsidence by pressure often produces dangerous cerebral 
symptoms. Spina bifida is the counterpart of hydrocephalus, and the 
two often coexist. If we compress the hydrocephalic head the spinal 
tumor increases, and vice versa. Club-foot is another not infrequent 



5^8 



SPINA BIFIDA 



complication. In the case which is represented in the accompanying 
woodcut, hydrocephalus, spina bifida, and clubfoot coexisted. The 
child was brought to the children's class in the Outdoor Department at 
Bellevue, and after a few visits I lost sight of it. It probably died soon 
after, since the tumor, over which the cuticle was wanting, presented 
a deep red appearance as if inflamed, so that ulceration and escape of 
the fluid seemed near at hand. There is ordinarily but one spina bifida, 
the common seat of which is the lumbar region, but occasionally two or 
more are present. If the aperture through which the tumor protrudes 
be small, it is usually pedunculated, but if large, it is sessile. In some 
patients it is covered by skin, which may be normal or somewhat indu- 
rated ; in others the skin is absent over the entire tumor or its most 
prominent part, and the dura mater or the connective tissue lying di- 
rectly over the dura mater is exposed, and is liable to inflammation from 
friction. If the walls of the tumor be thin the liquid may transude in 
drops, and they are liable to give way by ulceration or rupture. Sudden 



Fig. 33. 




escape of the liquid, and collapse of the spina bifida, involve great danger, 
for convulsions, coma, and death are the probable result. 

The relation of the spinal cord or nerves, or of the cauda equina, to 
the tumor, is a matter of great importance. In many patients the adja- 
cent portion of the cord or cauda equina, is deflected through the aper- 
ture, and lies against the interior of the sac. Spinal nerves also not in- 
frequently lie within the sac, some returning into the spinal canal, and 
others passing through the walls of the sac to their points of distribu- 
tion. Those which are deflected into the tumor and return into the 
canal obviously lie lowest. In the most favorable cases, to wit, those 
with a small aperture, or small tumor, or a narrow and long peduncle, 
neither the cord, cauda equina, nor nerves lie within the sac. It is im- 
portant to the practitioner to bear in mind that in all probability, unless 
under the favorable anatomical circumstances stated above, the sac con- 
tains nervous elements. In rare instances the liquid, instead of lying 
externally to the cord, lies within its central canal. The substance of 



PROGNOSIS — TREATMENT. 549 

the cord then becomes distended, and it encloses the liquid like a deli- 
cate sac, just as the hemispheres of the brain are unfolded and expanded 
in the common form of congenital hydrocephalus. As might be expected 
from the anatomical characters of the more serious forms of spina bifida, 
paralysis, more or less complete, of the vesical and rectal muscular 
fibres, and paraplegia sometimes occur, in which event the fatal issue is 
probably not far distant. 

Diagnosis. — This is easy in ordinary cases. The congenital nature 
of the tumor, and the bony edge of the aperture, appreciable to the 
touch, suffice in ordinary cases to establish the diagnosis. The diminu- 
tion of the tumor by pressure, and its enlargement when the child cries, 
are important diagnostic signs. There are various lumbo-sacral tumors 
located in the median line, from which it is important that spina bifida 
should be diagnosticated. Sometimes a cyst occurs in this situation 
which was originally a spina bifida, but obliteration of the canal in the 
pedicle occurred, just as the canal connecting a hydrocele with the 
abdominal cavity closes. Solid congenital tumors sometimes also occur 
in the same situation, among which, as most common, may be men- 
tioned fatty tumors, and tumors containing foetal remains. The most 
common seat of tumors which enclose foetal remains is at the point 
where spina bifida ordinarily occurs. Physicians have erred in con- 
founding these tumors, as well as those which consist of fat, with spina 
bifida ; but a mistake in diagnosis can only occur through haste or 
carelessness of examination. 

Prognosis. — This is in most instances unfavorable. Ordinarily the 
tumor increases slowly, and finally the sac gives way by ulceration or 
rupture ; the liquid escapes, and death occurs in convulsions and coma; 
or, if the escape of the liquid be prevented by pressure, and the aper- 
ture closes, a second rupture is probable with a fatal result. In other 
cases the tumor may not rupture, but the cord is softened, or it is in- 
jurcd by being bent, so that paraplegia results, and death after a time 
occurs in a state of emaciation. Rarely the tumor may shrivel by ab- 
sorption of the liquid, and the disease is cured, or so nearly cured that 
it gives no inconvenience, and the patient lives for years. In other 
rare instances the tumor may remain without any material change, and 
without giving rise to symptoms. The spina bifida being small and 
covered with skin, and the aperture leading from it into the spinal canal 
being also small, the patient lives through the natural period of life with 
little inconvenience. 

Treatment. — It is evident, from what has been stated, that no fixed 
rule can be laid down for the treatment of the spina bifida. In the 
most favorable cases, in which no symptoms occur, and there is no indi- 
cation that the tumor will change or undergo any unfavorable change, 
surgical treatment is not required, except the application of a soft pad 
to support the tumor, so as to prevent its injury by friction. Indications 
which justify active surgical interference are growth of tumor, absence 
of skin from it, with tension of the parietes, so that an early rupture is 
inevitable, and dangerous nervous symptoms, as convulsions or para- 
plegia. 

From the nature of spina bifida it is evident that operations upon it 



550 SPINA BIFIDA. 

must be conducted with caution. The usual presence of the spinal cord 
in the pedicle and in the sac forbids ligation and excision, and renders 
attempts to obliterate the sac hazardous, by producing inflammation 
within it. A safe mode of treatment, but not the most efficient, is to 
puncture the sac and withdraw a portion of the liquid by a grooved 
needle or hypodermic syringe. A soft pad should then be applied to 
produce gentle compression. If no unfavorable symptoms occur, the 
puncture may be repeated after a day or two. This operation has been 
employed with a satisfactory result by Sir Astley Cooper among 
others; but, simple as it is, it is not devoid of danger, for the removal 
of the liquid, if carried beyond a certain point, may produce dangerous 
nervous symptoms, especially convulsions. In performing the opera- 
tion, the puncture should never be made in the median line, on account 
of the danger of wounding the cord, which lies against the median por- 
tion of the sac. The veins, also, should be avoided. 

Another mode of treatment is by iodine injections. They are pre- 
ferable to other methods, if the neck be long and pedunculated, so as to 
be easily compressed. If the tumor be sessile, and the aperture into the 
spinal canal be free, these injections involve great danger, and are not 
to be recommended ; for more or less of the solution will inevitably enter 
the spinal canal, and give rise to spinal meningitis. Iodine injections 
have been employed with success by Professor Brainard, of Chicago, 
who states that he " perfectly and permanently cured" three of seven 
cases ; and by Velpeau, of Paris, by whose method five in ten opera- 
tions were successful, and by many others. Professor Brainard with- 
drew some of the liquid contents, and then injected half an ounce of water 
containing 2 J grains of iodine, and 7 J grains of iodide of potassium. In 
a few seconds this was allowed to flow out, and the sac was then washed 
out with tepid water. Then a portion of the cerebro-spinal fluid, which 
had been kept warm, was returned into the sac. When he had with- 
drawn six ounces of this fluid he returned two ounces. In employing the 
iodine, or any other irritating injection, it is necessary to compress the 
pedicle, so that the liquid does not enter the spinal canal. Velpeau 
employed one part of iodine, one of iodide of potassium, and ten of dis- 
tilled water. 

During a debate in the Societe de Chirurgie, M. Debont recom- 
mended the evacuation of only a little of the fluid, and the injection of 
two or three drops of the tincture of iodine diluted with an equal quan- 
tity of water. T. Smith, 1 by the injection of one drop of the tincture, 
produced an amount of inflammation which nearly obliterated the sac. 
'Since statistics show so good a result of iodine injections, this mode of 
treatment seems preferable to any other for certain cases, and as one 
drop has produced general inflammation of the sac and nearly oblite- 
rated it, it seems safest and best to begin with so small a quantity. 

If there be reason to believe, from the small size of the orifice and 
other anatomical characters, that neither the cord, cauda equina, nor any 
of the spinal nerves lie, within the sac, it may be thought best to remove 
the tumor. It has, indeed, been proposed to open the tumor, immersed 

1 Holmes's Surs;. Dis. of Children. 



' VERTEBRAL CARIES. 551 

under warm water sufficiently to observe the relation of the nervous ele- 
ments, and to press them back gently into the canal if they lie within 
the sac. If it be decided to remove the spina bifida, a clamp, or elastic 
band, is placed around the pedicle so snugly as to cause firm adhesion 
of the walls of the pedicle, and excite sufficient inflammation in them 
to produce agglutination, but without causing strangulation or sup- 
puration. 

After a time, perhaps two or three days, when it is evident that agglu- 
tination has occurred from the fact that the liquid cannot be returned 
within the spinal canal by compressing the sac, the tumor may be re- 
moved by the knife or ecraseur. Statistics do not show so favorable a 
result of this operation as of the iodine treatment, and the reason is 
obvious for it is only in exceptional cases that the tumor can be re- 
moved without injury to the nervous tissue, and excision of a portion 
of the cord, or of important nerves, either produces death or a condi- 
tion to which death would be a relief. 

Spina bifida has also been treated by opening the sac on its side, 
pressing back the spinal cord or its nerves into the spinal canal, uniting 
the edges of the wound, and then applying pressure to prevent protru- 
sion, but the result has not been favorable. Treatment by simple 
puncture, followed by compression, and if it fail, as it probably will, 
the cautious use of iodine injections is the preferable mode of treating 
ordinary cases of spina bifida which require surgical interference. 



CHAPTEE XIX. 

VERTEBRAL CARIES. 

Vertebral caries, designated also Pott's disease, occurs chiefly in 
childhood, but now and then adults are affected with it. It is an osteitis 
of the bodies of one or more vertebras, ending in their ulceration and a 
lifelong deformity, if not checked. 

Causes. — A reduced state of system, and especially the scrofulous 
diathesis, strongly predispose to caries. Hence this malady is more 
common in the city than in the country, where better hygienic condi- 
tions produce a more vigorous constitution. Prolonged antihygienic 
conditions and protracted ill-health from whatever cause predispose to 
caries. In certain cases, there is no apparent exciting cause, while in 
others there is the history of a fall upon or some injury of the spine. 

Vertebral caries may occur in the cervical, dorsal, or lumbar portions 
of the spinal column, but it is more common in the lower dorsal than 
elsewhere. With the development of the osteitis, the body of the verte- 
bra which is affected becomes hyperaemic, and the spongy tissue is soon 



552 VERTEBRAL CARIES. 

infiltrated with blood and pus. The bone becomes swollen and softened, 
and, therefore, less resisting than in the healthy state, so that it yields 
under the weight of the shoulders and head, which it sustains. There- 
fore, after the osteitis has continued a certain time, there begins to be 
posterior convexity or rather angularity of the spine, for while the verte- 
bral bodies soften and yield by the weight above them, the arches retain 
their integrity and firmness, and are unyielding. 

Much of the tediousness and suffering of this malady are due to the 
fact that the inflammation is so deep-seated, and a healthy bony barrier 
is interposed between it and the surface, so that there is no ready escape 
of the pus. It permeates the spongy tissue, filling the cavities produced 
by the softening and absorption of the bone-substance. If the inflam- 
mation be of small extent, the amount of pus small, the constitution 
good, and if the disease be early recognized and properly treated, the 
child may recover without any fistulous opening, by absorption of the 
pus, and with little remaining deformity. 

In the large proportion of cases, however, the history is different. 
The disease is not recognized till the stage of deformity, the caries is so 
extensive and the pus so abundant, that it escapes between the vertebra?, 
forming an abscess external to" them, which connects with the interior 
of the vertebrae by a fistulous canal. This abscess if in the cervical 
region may press upon the pharynx or oesophagus, or upon the air-pas- 
sages, producing dangerous obstruction to the respiration. (See Art. 
Retro-pharyngeal Abscess.) The pus may point and discharge exter- 
nally near the seat of the caries, but in a large proportion of instances 
it takes a long and circuitous route to the surface, or it opens internally. 
There are instances in which it discharges into the pleural or abdominal 
cavity, or into one of the abdominal organs. If, as is sometimes the 
case, it establishes a connection with the intestine and escape in the 
stools, the result will probably be favorable. In other instances it 
descends into the pelvic cavity, and finds an outlet by the inguinal ring, 
or sciatic notch, or it enters the sheath of the iliacus or psoas muscle, 
and points externally. 

When the disease ends favorably, new bone is thrown out around the 
diseased vertebras, preventing further bending, and giving stability to 
the spine. If the abscess do not discharge, but remain subcutaneous, 
Billroth says: . . . "While the bone disease > recovers most fre- 
quently, a large part of the pus, whose cells disintegrate into fine mole- 
cules, is absorbed, while the inner walls of the abscess change to a cica- 
tricial tissue, which in the shape of a fibrous sac contains the puriform 
fluid. Such pus-sacs often remain in this stage for years." 

If the pus have escaped externally, the abscesses and fistulas contract 
and finally close, their site being occupied by condensed connective 
tissue. The portions of the diseased vertebrae which have retained their 
vitality are enveloped and supported by the new bone, so that the part 
of the spine which was the seat of the disease, though anchylosed and 
curved, has greater firmness than in health. 

The history of unfavorable cases varies ; the caries may extend. Pus 
finding no vent may accumulate in cavities and sinuses, in which de- 
tached portions of bone float, or it may make its way in such directions 



DIAGNOSIS. OOO 

that it produces alarming complications, and impairs or obstructs the 
functions of important organs. 

Spinal meningitis in the vicinity of the caries, and clue to extension 
of the inflammation, is common, and "the spinal medulla," says Bill- 
roth, a may be endangered by participation in the suppuration, or by 
being so bent by the inclination of the vertebrae, that its function is 
destroyed." Hence the paralysis of the lower extremities, bladder, and 
rectum, which occurs in aggravated cases, and which entails a fatal issue. 
In a certain proportion of cases the blood becomes more and more im- 
poverished from the continuance of the inflammation and suppuration, 
and death occurs in a state of exhaustion. In such cases post-mortem 
examination often discloses waxy degeneration of important organs, as 
the spleen, liver, kidneys, and intestines, for it is well known that 
chronic suppurative inflammation of the bones is one of the two chief 
causes of the waxy disease, syphilis being the other. 

Symptoms. — Caries of the vertebrae is often preceded by symptoms 
or appearances which are due to the strumous cachexia. Strumous 
ailments have probably occurred in the patient, or in members of the 
family, or without any clear history of struma the child has perhaps for 
some time been in failing health. In cases which I have observed, one 
of the chief symptoms, and sometimes almost the only symptom in the 
commencement of the caries, has been neuralgic pain, usually not severe, 
intermittent, or more or less constant, at some point in the anterior 
aspect of the body, most frequently in the chest, epigastric, or umbilical 
region. This pain has been present in a larger proportion of cases, 
than pain in the spinal region at the seat of the caries, though Guersant 
dwells particularly upon the latter as a symptom of caries. Patients 
with this neuralgia are not infrequently treated for indigestion, or 
worms, the true nature of the malady not being suspected, and the spine 
not even being examined. This neuralgia seems to be due to compres- 
sion of the spinal nerves, by inflammatory exudation at the points where 
they emerge from the spinal canal. I can recall to mind a number of 
cases in w T hich I have on different occasions been asked to prescribe for 
this neuralgia, which was shown by the sequel to be undoubtedly the 
result of vertebral caries, and yet with a careful examination of the 
spinal column could discover no evidences of disease at any point. After 
a time, tenderness, pain, and inflammatory induration, appreciable to the 
touch, may occur in or along the spine, but not usually till the malady 
is well advanced. Lassitude, fatigue after slight exertion, poor appetite, 
with slight fever, are common symptoms in the first stage of the caries. 

As the case advances, if the nature of the disease be not recosi;- 
nizad, and no artificial support of the trunk be provided, the child in- 
stinctively seeks some way of supporting the head and shoulders. He 
rests his head upon his hands, or his elbows upon the table. Soon a 
gibbosity or angularity appears, affording clear and positive proof of the 
nature of the disease. Even now there is little or no tenderness when 
pressure is made directly on the spine, but it is observed more when 
pressure is made laterally upon it. If the inflammation extend so as to 
involve the meninges and the cord, pricking, tingling, numbness or 
weakness of the legs may occur, which are symptoms of grave import. 



554: VERTEBRAL CARIES. 

for it is probable that the case will end in paraplegia and death. A 
state of emaciation and general weakness, sometimes accompanied by 
diarrhoea and oedema of the limbs, precedes death. But a very consid- 
erable degree of curvature is not incompatible with a healthy and normal 
performance of all the functions, and the number who recover, and live 
to an advanced age with deformity, is large, as every one knows. 

Diagnosis. — This is often from the nature of the disease obscure and 
uncertain for a time. The long continuance of pain in the chest or 
abdomen, or perhaps in the thighs, without any cause which we can de- 
tect, located at the seat of the pain, should excite suspicion of spinal dis- 
ease. Such pain may be produced by spinal irritation, but in this 
malady pressure on the spine is badly tolerated, and when we touch a 
certain part, the neuralgic pain is intensified. In caries, as we have 
seen, firm pressure upon the spine is tolerated, and it does not increase 
the neuralgia. At a later period in caries there may be spinal pain 
and tenderness, but there is now also spinal deformity, by which alone 
the diagnosis is clearly established ; stiffness observed in the movements 
of the spine, pain in the spine, on sudden movement or jarring the body, 
impaired appetite and general health, and instinctive desire to sit or 
recline in such a way as to relieve the spine partially of the weight of 
the head and shoulders, are symptoms which, if they coexist, afford very 
strong evidence of the presence of caries, although there be as yet no 
deformity. 

The spinal deformity of rachitis is distinguished from that of caries, 
by the fact that it occurs slowly without pain or tenderness, and is 
rounded instead of angular. Moreover, the rachitic diathesis precludes 
scrofulous ailments, and the scrofulous diathesis rachitic ailments, as the 
two diatheses do not coexist, or but rarely ; so that if there be in the 
state of the patient or have been in his history evidences of scrofula, the 
presumption is that the bending of the spine occurs from caries. In a 
case of rachitic curvature, we find also enlargements of the ankles and 
wrists, keel-shaped thorax, prominent abdomen, rachitic head, etc. 

Prognosis. — The course of this malady, even when the caries is 
slight and the symptoms mild, is tedious. In the most favorable cases 
the general health is but slightly impaired, the caries is confined to one 
vertebra, and is early diagnosticated and properly treated. On the 
other hand, if the general health be decidedly poor, the child anaemic 
and wasted, the curvature great, and an abscess have occurred, the case 
is very serious. Between these two extremes is every grade. The 
prognosis is more favorable in the child than in the adult. The few 
adults whom I have seen with it ail died. It is less favorable in the 
cervical region than in the dorsal or lumbar. A mild case occurring in 
a good condition of health may become grave and even fatal by neglect 
and improper treatment. A majority of the patients, if the disease be 
not too far advanced when recognized, recover if properly treated, but 
the deformity which results may prove serious in after-life. The incom- 
plete expansion of the lungs in the humpbacked, greatly increases the 
danger and the dyspnoea in bronchitis and pneumonia, and if the caries 
have been at a low point in the spine, and the patient a female, the de- 
formity will probably present an obstacle to chilclb earing. 



TREATMENT. 555 

Treatment. — The treatment must be constitutional and local, hy- 
gienic, medicinal, and mechanical. It is of the utmost importance to 
improve the general health, as it is in all chronic inflammations and 
scrofulous ailments. Pure air, sunlight, personal cleanliness, and plain 
but the most nutritious diet are required. Tonic and antistrumous 
remedies are indicated. To many patients I have prescribed, three 
times daily, cod-liver oil, to which the syrup of the iodide of iron was 
added, giving two drops to a child of one year, and one additional drop 
for each additional year. The judicious use of alcoholic stimulants will 
often be found useful, if the appetite be poor and general health seri- 
ously impaired, as will also the vegetable bitters. 

In all strumous inflammations of the bones, which extend to or in- 
volve joints, and which are in their nature chronic, perfect quiet of the 
parts, so far as it is consistent with the degree of exercise which is re- 
quired in order to improve the appetite and general health, is indispen- 
sable for successful treatment of the case. The patient with this malady 
should be encouraged to lie much of the time in bed, for the double 
purpose of preventing movements of the inflamed vertebrae, and re- 
lieving them of the weight of the shoulders and head. But confinement 
in bed is badly tolerated, and exercise is necessary for a healthy func- 
tional activity of the organs ; therefore mechanical support of the spine 
is required. The apparatuses which have been invented for the purpose 
of supporting the spine and rendering it immovable, and of sustaining 
the head, if the caries be in the cervical region, or the head and shoul- 
ders, if it be in the dorsal or lumbar region, are ingenious and effectual. 
Some of them are rather cumbersome, but others are sufficiently light 
for the youngest child who can walk. The apparatus should be worn 
for months, care being taken to prevent excoriation or undue pressure 
upon any point. It may be removed at night, and reapplied on rising 
in the morning. 



SECTION II. 

DISEASES OF THE RESPIRATORY SYSTEM. 



CHAPTER I. 

CORYZA. 

The term coryza is applied to inflammation of the Schneiclerian 
membrane. It is acute or chronic. The acute form is primary or sec- 
ondary. Acute primary coryza is common in infancy and childhood. 
Its usual cause is exposure to currents of air, to cold, and especially to 
sudden changes of temperature from warm to cold. The cause is the 
same as that in the ordinary forms of bronchitis. These two diseases 
frequently indeed coexist, occurring from the same exposure. The in- 
flammation in such cases commences upon the Schneiclerian membrane, 
immediately upon the operation of the cause, and soon after extends to 
the bronchial tubes. Acute coryza may also be produced by the inha- 
lation of irritating vapors, hot air, or dust, and also by the presence of 
a foreign body, as a button or bean, in the nostril. 

Secondary coryza is commonly due to a specific cause. The diseases 
in connection with which it occurs are hooping-cough, measles, scarlet 
fever, diphtheria, and constitutional syphilis. In the infant, coryza is 
one of the first manifestations of hereditary syphilitic taint. 

Acute primary coryza ordinarily abates in from one to two Aveeks. 
The secondary form gradually declines, in most cases,* when the primary 
affection on which it depends is cured. Syphilitic coryza is more pro- 
tracted than the primary form, or than that accompanying the eruptive 
fevers. Some children are so liable to coryza that it occurs whenever 
they take cold. Occasionally it is so frequently renewed in the winter 
months that it resembles the chronic form of the disease. 

Chronic coryza is commonly dependent on a clyscrasia, usually the 
syphilitic or strumous. The dyscrasia is indicated by pallor, flabbiness of 
the flesh, and liability to glandular swellings. Certain cases take their 
origin in the nasal catarrh of the exanthematic fevers, the local affec- 
tion continuing after the constitutional disease has declined. Chronic 
coryza sometimes occurs in children who appear otherwise in good 
health. It is probable that in such cases there is a dyscrasia of which 
the coryza happens to be the sole manifestation. 
( 556 ) 



SYMPTOMS — PROGNOSIS — TREATMENT. 557 

Anatomical Characters. — The alterations which the nasal mu- 
cous membrane undergoes when inflamed vary considerably in different 
cases. In the simplest and most common form of coryza, this mem- 
brane is sometimes in patches, sometimes generally reddened, thick- 
ened, and softened. Its papillae are prominent, producing an inequality 
of the surface. Ulcerations are not common in simple acute coryza, 
but they sometimes occur in the chronic form. 

In diphtheria, and sometimes in scarlet fever and variola of severe 
type, the coryza is pseudo-membranous, and when it presents this form 
it is commonly but not always associated with pseudo-membranous 
angina or laryngitis. A case of pseudo-membranous coryza occurring 
in measles is related by M. Guibert. The patient was a rachitic boy, 
three and a half years old. The pseudo-membrane, in grave cases, 
may cover almost the entire surface of the nostrils, but ordinarily it 
occurs in patches. 

Symptoms. — The constitutional symptoms are mild or severe, accord- 
ing to the gravity of the inflammation. If the coryza be acute and 
pretty general, there is febrile movement, with thirst and loss of appe- 
tite. Frontal headache is common, from the proximity of the inflam- 
mation to the head, or its extension to the frontal sinuses. Sneezing is 
the first symptom in many cases of acute coryza. As the inflamed 
membrane swells, more or less obstruction occurs to respiration. The 
breathing is noisy, especially during sleep, and in severe cases the pa- 
tient is compelled to breathe mostly through the mouth. If there be 
much obstruction to respiration the suffering of the patient is consider- 
able, from the sensation of fulness in the nostrils, the headache, and the 
muscular effort required in each respiratory act. 

In the commencement of coryza the patient experiences a sensation 
of dryness in the nostrils, which is soon succeeded by a thin discharge 
of a serous appearance. In the course of a few hours the secretion 
becomes thicker. It is muco-purulent, and remains such till the disease 
begins to decline. Inspissated mucus and crusts are liable to collect 
within the nostrils and around their orifice in chronic coryza, and some- 
times also in the acute disease, if the discharge be not abundant. These 
crusts increase the difficulty of breathing. Often the acridity of the 
discharge is such that the skin of the upper lip and around the nostrils 
is excoriated. 

Prognosis — Uncomplicated catarrhal coryza rarely terminates fatally. 
It is only dangerous in young nursing infants, in whom it may seriously 
interfere with lactation. Coryza, accompanying the eruptive fevers, 
although it may increase the suffering, does not materially increase the 
danger. Syphilitic coryza subsides when the system is sufficiently 
affected by antisyphilitic remedies. Chronic coryza is sometimes very 
obstinate. It may continue for months or years, giving rise to a con- 
stant, but often not abundant, discharge. 

Treatment. — Common mild attacks of coryza require little treat- 
ment. The bowels should be kept open, the feet soaked in mustard- 
water, and the body should be warmly clothed. Inunction of the nos- 
trils is a popular remedy, and it seems to give some relief. If coryza 
commence with symptoms which indicate a pretty severe attack, and 



558 CORYZA. 

there are evidences of extension of the disease toward the bronchial 
tubes, an emetic of syrup of ipecacuanha, given at an early period, mode- 
rates the severity of the inflammation and may prevent the occurrence 
of bronchitis. Afterward a simple diaphoretic mixture, as the follow- 
ing, should be given: 

R. — Syrupi ipecacuanha gij. 

Spirit, asther. nitr. ^j. 

Syrupi simplicis ^ij. — Misce. 

One teaspoonful every three hours to a child of six months. In place 
of sweet spirits of nitre, acetate of potassium may be employed in the 
dose of one or two grains for infants; and if there be decided febrile re- 
action, from half a minim to two minims, according to the age, of tinc- 
ture of digitalis, should be added to each dose. 

A three to five per cent, solution of common salt in w T arm water in- 
jected into the nostrils with a small syringe, aids materially in removing 
the muco-pus which obstructs the respiration, and in establishing a 
healthier state of the inflamed surface. I have employed in the same 
way, with apparent benefit, carbolic acid, glycerine and water, to which 
the borate of sodium or a few T grains of chlorate of potassium have been 
added. This may also be conveniently used in the form of spray, with 
the steam atomizer, or thrown up the nostrils with the hand atomizer. 
The officinal lime-water is also a most useful .detergent of the nasal sur- 
face. The following formula will be found useful in most cases of this 
form of coryza. It should be injected w T arm several times daily : 

R. — Sodii chloridii ....... gj. 

Sodii borat gij. 

Aquae ....... . Oj. — Misce. 

The treatment proper for pseudo-membranous or diphtheritic coryza 
is detailed in our remarks on the therapeutics of diphtheria. Chronic 
coryza, since it depends upon a dyscrasia, of which it is one of the local 
manifestations, requires remedies appropriate for the blood disease. 
Scrofula needs the syrup of the iodide of iron and cod-liver oil. The 
various ferruginous preparations, as wine of iron, tincture of the chloride 
of iron, iron lozenges, and the vegetable tonics are also more or less use- 
ful. The diet should be nutritious and plain, arid outdoor exercise, 
and, if possible, country life, should be enjoined. 

If the dyscrasia be syphilitic, similar invigorating measures are re- 
quired, and mild mercurial inunctions to the nasal surface are especially 
useful. The following, which has been largely employed in the Out- 
door Department at Bellevue, is one of the best ointments for such 
cases, and its alterative effect renders it also useful for strumous coryza : 

R. — TJng. hydrarg. nitratis 5ij< 

Ung. zinci oxid. ....... 3 ij- — Misce. 

To be thoroughly applied to the Schneiderian membrane by a swab 
or camel's-hair pencil three or four times daily. Recently it has been 
modified by the substitution of Squibb 's five per cent, oleate of mercury 



CATARRHAL LARYNGITIS. 559 

in place of the citrine ointment. If the coryza have a distinctly syphilitic 
origin, the application of a two or three per cent, oleate of mercury will 
fully meet the indication and be followed by improvement. 

Meigs and Pepper recommend the following ointment in chronic 
coryza, to be applied at night, after the use of injections through the 
day: 

1£ . — Unguenti hydrargyri nitratis .... ^ss. 

Extract! belladonnse . gr. x. 

Axungias ^ss. — Misce. 

Astringent injections into the nostrils are not often required in the 
treatment of the various forms of coryza; but occasionally, if the dis- 
charge be protracted and abundant, weak astringent applications may 
be beneficial, as two or three grains of nitrate of silver, or of alum or 
tannin, to the ounce of water. It should be borne in mind that washes 
for the nasal surface should, as a rule, be employed tepid. 



CHAPTEE II. 

CATAKEHAL LABYNGITIS. 

Acute catarrhal laryngitis occurs at all ages, but it is so common in 
infancy and childhood, that it is proper to treat of it in a work relating 
to the diseases of these periods. Like other inflammatory affections of 
the air-passages, it is most common in the cold months, or when the 
weather is changeable. Its usual cause is, therefore, exposure to cold. 
Protracted and violent crying, and the inhalation of acrid vapors are 
occasional causes. Catarrhal, or as it is sometimes designated simple 
laryngitis, also occurs in connection with certain constitutional diseases, 
among which may be mentioned measles, scarlatina, and variola. Laryn- 
gitis is also a common accompaniment of bronchitis, and not infrequently 
of pneumonitis, though its symptoms are liable to be obscured by those 
of the graver disease. It often likewise accompanies pharyngitis, due 
to extension of the inflammation. 

Symptoms. — Catarrhal laryngitis produced by the impression of cold, 
is commonly preceded and accompanied by coryza. The initial symp- 
tom is chilliness, followed by sneezing, and the discharge of thin mucus 
from the nostrils in consequence of irritation of the Schneiderian mem- 
brane. 

The commencement of laryngitis is indicated by hoarseness, which is 
apparent when the child cries, or, if old enough, when it attempts to 
speak. There is often in severe cases complete loss of voice, so that 
speech above a whisper is impossible. I have noticed this most fre- 
quently in the laryngitis which accompanies measles. A cough occurs 



560 CATARRHAL LARYNGITIS. 

which is at first dry and husky but becomes loose in the course of a few 
days. Expectoration is scanty, unless the inflammation have extended 
to the trachea and bronchial tubes. 

This disease is often accompanied by soreness of the throat, noticed 
in the act of coughing or when the larynx is pressed with the finger. 
In laryngeal catarrh, when uncomplicated, the respiration remains 
nearly natural and the pulse is but little accelerated. In mild cases the 
nature of the disease is often not apparent as long as the child remains 
quiet, in consequence of the absence of symptoms, but the character of 
the voice when it cries or speaks, or of the cough, reveals at once the 
nature of the affection. 

Acute laryngeal catarrh subsides in from one to two weeks. Occa- 
sionally it lasts three or four weeks before the symptoms entirely dis- 
appear. Death, which is rare, is due to some complication. 

Chronic laryngitis is much less frequent than the acute form. Its 
anatomical characters are similar to those in other chronic inflamma- 
tions affecting mucous surfaces, to wit. thickening and more or less in- 
filtration of the mucous membrane, increased proliferation and exfoliation 
of the epithelial cells, and increased functional activity of the muciparous 
follicles. 

In the adult, chronic laryngitis is common as one of the lesions of the 
syphilitic or tubercular disease. In the child syphilitic and tubercular 
laryngitis is more rare, but the latter sometimes occurs in connection 
with pulmonary or bronchial tuberculosis. Such patients are emaciated, 
and have the ordinary symptoms of the tubercular disease. Chronic 
laryngitis also occurs in young children, usually infants, as one of the 
manifestations of the strumous diathesis. I have records of several such 
cases, mostly nursing infants. Some of these patients had mild bron- 
chitis, but it was obviously subordinate to the laryngitis. Their respira- 
tion was noisy and harsh, continuing of this character for several weeks 
and even months. The cough was also harsh and loud, conveying the 
idea of thickening and relaxation of the mucous membrane covering the 
vocal cords. Their respiration was not notably accelerated, and the 
blood was apparently fully oxygenated, though the friends were often 
alarmed by the noisy breathing and cough. 

In this form of chronic laryngitis expectoration is scanty, the fever 
slight or absent, the appetite remains unimpaired, and the general con- 
dition of the child is good. From time to time exacerbations occur, 
and occasionally improvement is such as to encourage the hope of speedy 
cure, but in the cases which I have seen there has not been complete 
intermission in the disease till the final recovery. Those patients whom 
I have been able to follow through the disease have recovered in from 
three or four months to one year. 

Chronic laryngitis is to be distinguished from frequent attacks of 
acute laryngitis, which are due to fresh exposures, and also from the 
laryngitis which is associated with bronchial phthisis. It is to be dis- 
tinguished from protracted acute laryngitis, which sometimes does not 
entirely subside in less than a month or six weeks, by its longer dura- 
tion, the greater thickening of the inflamed membrane, and more noisy 
respiration. Often chronic laryngitis results from the acute disease, 



TREATMENT. 561 

the inflammation being perpetuated by the struma or dyscrasia of the 
patients. 

Anatomical Characters. — In acute catarrhal laryngitis the mucous 
membrane of the larynx presents the usual appearances of mucous sur- 
faces when inflamed, namely, redness and thickening. It is also more 
or less softened. Ulcerations rarely, perhaps never, occur in primary 
acute laryngitis. When present in chronic laryngitis, the ulcers are 
small and situated upon or near the vocal cords. Tubercular and syphi- 
litic ulcers of the larynx are much more rare in children than in adults. 
The inflammation in simple acute laryngitis usually extends over the 
whole surface of the larynx, and also to the upper part of the trachea. 
It may be pretty uniform, or more intense in one place than another, 
and, like other mucous inflammations, it is accompanied by more or less 
proliferation and exfoliation of epithelial cells. In most cases of simple 
laryngitis, whether acute or chronic, the inflammation extends to the 
pharynx, producing redness and thickening, though generally moderate, 
of the mucous membrane which covers it. Examination of the fauces 
therefore aids in diagnosis. 

In the adult oedema glottidis occasionally results from laryngitis. In 
the child there is little danger that this will occur, in consequence of 
the anatomical character of the larynx, since in early life the larynx 
contains but little submucous connective tissue, and therefore less sub- 
mucous infiltration or effusion occurs during the inflammation. The 
structural changes occurring in catarrhal laryngitis of infancy and child- 
hood relate almost exclusively to the mucous membrane. 

Treatment. — Primary and uncomplicated catarrhal laryngitis re- 
quires little treatment. Most cases do well by the employment of 
suitable hygienic measures, without medicines. Benefit is, however, 
derived from the use of demulcent drinks and an occasional laxative. 
A mixture of paregoric and syrup of ipecacuanha, or the mist, glycyr. 
comp., or a small Dover's powder, will relieve the cough. For restless- 
ness, a warm foot-bath is also useful. Inhalation of the spray of gly- 
cerine and water from the atomizer, or of steam, plain or medicated, is 
also useful. Mildly stimulating embrocations, as by camphorated oil 
with or without a little turpentine, also aid. It should be rubbed sev- 
eral times daily over the throat, or a strip of flannel soaked with it may 
be applied around the neck. Chronic laryngitis dependent on syphilis 
or tuberculosis requires the constitutional treatment which is appropriate 
for that disease. Measures not specific have little effect upon this form 
of inflammation. The chronic laryngitis which I have described as 
occurring chiefly in infancy, and which appears to be of a strumous 
character, is in most cases obstinate. The patient should be warmly 
clothed, and constant care should be taken that there be no exposure 
which would endanger taking cold, as this would produce an exacerba- 
tion of the disease, and tend to counteract what had been gained by 
remedial measures. This form of chronic laryngitis is most satisfacto- 
rily treated by the application of tincture of iodine upon the neck, 
directly over the larynx, and the internal use of cod-liver oil and the 
syrup of the iodide of iron. No benefit results in this inflammation 
from expectorant remedies, as squills or senega. 

36 



562 SPASMODIC LARYNGITIS. 



Spasmodic Laryngitis. 



This is a common disease. It is also called false croup, in contra- 
distinction to true or pseudo-membranous croup, and, by some conti- 
nental writers, stridulous angina or stridulous laryngitis. It should 
not be confounded with spasm of the glottis, which is a form of inter- 
nal convulsions, and is not inflammatory. It occurs ordinarily between 
the ages of two and five years. It is commonly a sporadic affection, 
but Killiet and Barthez state that "it is incontestable that it may pre- 
vail epidemically." They express this opinion, not from their own 
observations, but chiefly from those of Jurine, made in the commence- 
ment of the present century. 

Causes. — Children in some families are more liable to false croup 
than in others, so that an hereditary tendency to it must be admitted. 
The exciting cause in most cases is exposure to cold. False croup is 
not uncommon in the commencement of measles. Narrowness of the 
rima glottidis, and an excitable state of the nervous system, both of 
which are common in early childhood, are predisposing causes. 

Symptoms. — Spasmodic laryngitis is ordinarily preceded for a day or 
two by a slight cough and fever, by symptoms of mild nasal catarrh, 
such as all children are liable to on taking cold. In exceptional cases 
these symptoms are absent and the disease begins abruptly. Singu- 
larly, it commences in most patients at night, after the first sleep, be- 
tween ten and twelve o'clock. The sleep is usually quiet and natural, 
but the child awakens with a loud, barking cough. There is great 
dyspnoea, and the respiration is harsh or whistling, on account of the 
narrowing of the chink of the glottis from the swelling and tension of 
the vocal cords. The face is flushed and expressive of suffering. The 
child cries, moves from one position to another, wishes to be held or 
carried, seeking in vain for relief. The skin is hot, pulse accelerated, 
the voice hoarse or even whispering. After a variable period, usually 
from half an hour to two or three — not more than half an hour with 
proper treatment — these symptoms abate. The patient is then some- 
wdiat exhausted and falls asleep. The face is less flushed or even pallid, 
the heat abates, and the pulse is less accelerated. The cough, though 
less frequent, remains for a time barking or sonorous, and respiration, 
though greatly relieved, is not at once entirely natural, but it gradually 
becomes so. In many cases the spasmodic respiration and cough do 
not recur, but sometimes the attack is repeated once or more, especially 
during the subsequent nights. The symptoms vary greatly in intensity 
in different patients. 

As the attack declines, the disease, losing its spasmodic character, 
becomes a simple inflammation. In some patients the abatement of the 
cough and restoration of health are rapid, but oftener the inflammation 
extends not only into the trachea, but also into the larger bronchial 
tubes, and a tracheo-bronchitis remains, which gradually declines. 

The termination is not always so favorable. Spasmodic laryngitis is, 
in exceptional instances, the precursor of other serious affections, which 
may prove fatal. It has been stated that measles often begins with 



'diagnosis. 563 

spasmodic laryngitis. Bronchitis becoming capillary, may occur in 
connection with it, as may also pneumonia, and by either of these 
severe inflammations the prognosis may be rendered doubtful. A few 
cases have been recorded in which it was believed that spasmodic laryn- 
gitis was of itself fatal. In some of these the dyspnoea was extreme 
and persistent, and was the cause of death. In a case reported by 
Rogery, on the other hand, the respiration became easy before death, 
and the pulse more and more frequent and feeble. Death apparently 
occurred from exhaustion. It is not improbable that, had careful post- 
mortem examinations been made in those cases of spasmodic laryngitis 
which have ended fatally, other lesions would have been discovered be- 
sides those located in the larynx, perhaps tracheo-bronchitis, with an 
accumulation of mucus in the larynx, producing suffocation, or perhaps 
in some of the cases congestion of the brain or lungs and serous effusion. 

Anatomical Characters — Pathology. — The opportunity does not 
often occur of determining the anatomical characters of spasmodic laryn- 
gitis. I have witnessed but one post-mortem examination. A little 
girl, nine years old ; was taken on Friday night with cough and dys- 
pnoea, indicating a pretty severe attack.^ The mother, acting through 
the advice of a friend, gave kerosene oil to her in considerable quantity. 
This was succeeded by obstinate vomiting and purging, which continued 
during Saturday and Sunday, and terminated fatally on Monday. At 
the autopsy we found uniform and intense injection throughout the 
whole extent of the larynx and trachea and in the bronchial tubes, but 
there was no pseudo-membrane on the inflamed surface, and but little 
mucus and pus. The solitary follicles of the intestines and Peyer's 
patches were tumefied, and the gastro-intestinal surface was injected in 
places. The cause of death was obviously the diarrhoea, apparently of 
an inflammatory character, and probably produced by the kerosene oil. 
The condition of the mucous membrane of the larynx was that which is 
ordinarily present in spasmodic laryngitis, though in some cases in 
which post-mortem examinations have been made the evidences of laryn- 
geal inflammation were slight. Guersant relates a case in which the 
surface of the larynx seemed to be nearly in its normal state. Death 
in cases of slight laryngitis is due to causes which are independent of 
the larynx. In Guersant' s case tuberculosis was present. 

There is, as has already been intimated, another and a more important 
element besides the inflammation in the pathology of spasmodic laryn- 
gitis — an element producing those phenomena which render it a disease 
distinct from simple laryngitis. I refer to spasm of the laryngeal mus- 
cles. This element pertains to the nervous system, so that spasmodic 
laryngitis is allied both to the neuroses and to inflammation. 

Diagnosis. — The disease for which spasmodic laryngitis is most fre- 
quently mistaken is pseudo-membranous croup. The friends, indeed, 
usually make this mistake in forming their opinion of the case before 
the physician arrives ; and there can be no doubt that many of the 
cases which have been published in medical journals as true croup 
were examples of this affection. The points of differential diagnosis 
are the following : True croup begins with symptoms which at first are 
slight, so as scarcely to arrest attention, but which gradually increase 



564 SPASMODIC LARYNGITIS. 

in intensity. The cough becomes more harsh, and the respiration more 
difficult, by degrees. This increase in the gravity of the symptoms 
occurs by day as well as by night. On the other hand, false croup, 
though preceded by symptoms of nasal catarrh, commences abruptly. 
The symptoms have from the first their maximum intensity, and the 
time at which it commences is at night. Again, the cough in spas- 
modic laryngitis possesses a loud, sonorous character ; while in true 
croup it is harsh or rough, from the presence of the membrane, and 
having, therefore, less fulness. The voice in spasmodic laryngitis may 
be hoarse, but it is not lost, or is lost only for a short time. It after- 
ward becomes natural, or is slightly hoarse. On the other hand, in 
true croup, the voice, from being natural at first, is gradually extin- 
guished. In fatal cases it soon becomes whispering, and continues such 
till the close of life ; in those that recover, the voice remains hoarse for 
several days. These differences are important, and, if fully appreciated, 
are in most instances sufficient to establish the diagnosis. Besides, in a 
large proportion of cases of true croup, portions of the pseudo-membrane 
may be discovered on inspecting the fauces, and the faucial surface is 
deeply injected, while in spasmodic laryngitis there is, with rare excep- 
tions, no false membrane upon the surface of the fauces, and but a mod- 
erate amount of congestion. 

Laryngismus stridulus, or internal convulsions, must not be con- 
founded with this disease. It is not inflammatory, but purely spas- 
modic, suddenly commencing and abating — identical, it is believed, in 
character with tonic convulsions of the external muscles, but aifecting 
the internal muscles of respiration. This disease has already been fully 
described. 

Prognosis. — Little need be added, as regards prognosis, to what has 
already been stated. While a favorable opinion in reference to the 
result may ordinarily be expressed, the physician should not forget the 
fact that death may occur. Symptoms indicating an unfavorable termi- 
nation are : great and continued dyspnoea, not diminished by the proper 
remedial measures ; stridulous expiration as well as inspiration ; lividity 
of the prolabia and fingers ; pallor and coldness of surface ; pulse pro- 
gressively more frequent and feeble. Convulsions and coma may also 
occur near the close of life. 

Treatment. — The indications of treatment are twofold : first, to 
relieve the spasmodic action of the laryngeal muscles ; secondly, to cure 
the laryngitis. To meet the first indication, a warm bath of the tem- 
perature of about 100° should be employed as soon as possible after the 
commencement of the attack. The patient should be kept in it ten or 
fifteen minutes, in order to obtain its full relaxing effect. In mild cases 
a warm foot-bath may be sufficient. A second means is the use of an 
emetic, which should be simultaneous with the bath. To children under 
the age of three years, syrup of ipecacuanha should be given, in doses 
of one teaspoonful, repeated in twenty minutes, till vomiting occurs ; or 
alum and syrup of ipecacuanha, two drachms of the former to one ounce 
of the latter, may be given in the same dose. The alum and the syrup 
produce more prompt emesis than the syrup alone. Children over the 
age of three years, unless of feeble constitutions, are best treated by the 



TREATMENT. 565 

compound syrup of squills in teaspoonful doses, or a mixture of this 
with syrup of ipecacuanha. It is not often necessary to give more than 
three or four doses, and sometimes one or two are sufficient to produce 
vomiting. 

In most cases, by the use of the warm bath and the emetic, the symp- 
toms are rendered milder, and convalescence soon commences. 

Dr. R. R. Livingstone 1 reports a case of laryngitis treated by Squibb's 
ether. It is stated that portions of pseudo-membrane, from one-eighth 
to three-fourths of an inch in length, were expectorated ; but the symp- 
toms certainly indicated a spasmodic element as decided as in spasmodic 
croup, and the benefit from the ether was apparently due to the relaxa- 
tion of the laryngeal muscles which it produced. The treatment of the 
patient, who was two years old, was commenced by the administration 
by the mouth of half a teaspoonful of the ether, and followed by its inha- 
lation. " In precisely eight minutes from the time the patient com- 
menced the inhalation, the abnormal muscular exertion ceased ; a gen- 
eral relaxation took place; the pulse (which had numbered 150) fell to 
100." Ether, judiciously employed, will probably prove to be a useful 
remedial agent in spasmodic forms of laryngitis, whether or not it have 
any effect on pseudo-membranous formations. A large majority of 
cases, however, recover speedily without its employment, or by the 
other measures recommended. 

Attention should always be given to the state of the bowels in spas- 
modic laryngitis; if they are not well open, a purgative should be ad- 
ministered. For those that are robust, and with considerable febrile 
movement, the saline cathartics are ordinarily preferable, as Rochelle 
salts, or a purgative dose of calomel may be administered. The cathartic 
should not be prescribed till the nausea from the emetic has subsided. 
By its derivative effect, it tends to diminish the laryngitis, and, in severe 
cases, it may obviate the need of depletion by leeches. 

Inhalation of the vapor of hot water, and the application of a sinapism 
over the neck and upper part of the sternum, followed by an emollient 
poultice, are useful adjuvants to treatment. 

The most convenient and effectual way of employing vapor is, how- 
ever, by the atomizer, and as the chief danger is that the inflammation 
may become pseudo-membranous, I am in the habit of using in the 
atomizer the officinal lime-water. 

When the spasmodic element in the disease is relieved, the case be- 
comes one of simple laryngitis, and the general plan of treatment recom- 
mended for that malady is proper for this. Small doses of ipecacuanha, 
or of one of the antimonial preparations, as the compound syrup of 
squills, not sufficient to cause nausea, should now be given at regular 
intervals. I have sometimes added to the expectorant one drop of the 
tincture of aconite root for robust children over the age of three or four 
years, having a full and rapid pulse, flushed face, and other evidences 
of active febrile movement. Its effect should be watched, and it should 
be discontinued when its sedative influence on the circulation begins to 

1 American Journal of the Medical Sciences, April, 1867. 



ol)() SPASMODIC LARYNGITIS. 

be apparent. It should not be given in the spasmodic laryngitis which 
occurs in the commencement of measles. 

If, however, the disease do not speedily terminate by recovery of the 
patient, or, more rarely, by death, there is nearly always tracheo-bron- 
chitis, or a more serious affection, coexisting with the laryngitis, or 
following it, so that depressing measures should not be long continued. 
Expectorants of a stimulating character, as carbonate of ammonium, or 
syrup of senega, are required in the course of a few days, and in young 
and feeble children they should be given at an early period. 

The mode of treatment recommended above is appropriate for that 
large class in whom the inflammatory element predominates. In a 
smaller number of cases the nervous element predominates over the 
inflammatory, and the treatment should be in some respects different. 
Such children are usually pallid and of spare habit, having, indeed, the 
nervous temperament. They are liable to attacks of this disease, though 
generally of a mild form, on slight exposure to cold, and with a very 
moderate amount of inflammation. The treatment in these cases should 
be directed more to the nervous system. My plan has been, in the 
treatment of such patients, after perhaps the use of a mild emetic, to 
give quinine, one grain three or four times daily, to a child from three 
to five years old, prescribing at the same time a simple expectorant, as 
syrup of squills, and a mildly irritating application to the throat. The 
symptoms in these cases are not severe, and active measures are not 
required, though the peculiar cough continues longer than in the more 
inflammatory forms of the malady. 

The patient with spasmodic laryngitis should be kept in a warm 
room during the paroxysms, and should inhale an atmosphere loaded 
w T ith moisture. 

Trousseau recommends a mode of treatment of spasmodic laryngitis 
which was first suggested by Graves, of Dublin. It consists in the 
application underneath the chin, so as to cover the larynx, of a sponge 
soaked in water as hot as can be borne ; in ten or fifteen minutes it is 
repeated. This reddens the skin, producing revulsion from the larynx. 
The hoarseness, dyspnoea, and cough diminish with this treatment, and 
some recover without other measures. 

Guersant and others speak of the importance of prophylactic man- 
agement of children who are liable to this disease. Attention should 

o 

be given to the dress, so that there may be sufficient protection from 
atmospheric changes, and there should be an equable temperature of the 
apartments in which they reside. Children of a decidedly nervous tem- 
perament, in whom the slightest laryngitis is liable to be spasmodic, re- 
quire additional prophylactic measures. They are pallid, and in a more 
or less cachectic state. Such children are benefited by chalybeate and 
vegetable tonics, and by exercise in suitable weather in the open air. 



MEMBRANOUS CROUP. 567 



CHAPTEE III. 

MEMBEANOUS CEOUP; DIPHTHEEITIC CEOUP; TEUE CEOUP. 

The term pseudo-membranous laryngitis, or laryngo-tracheitis, or 
true croup, is applied to a common and fatal disease, the essential ana- 
tomical character of which is inflammation of the larynx, or larynx and 
trachea, with the formation of a pseudo-membrane upon its surface. It 
occurs most frequently between the ages of two and twelve years, but 
infancy after the age of six months and early manhood are not exempt 
from it. For brevity I shall use the term croup in the following pages 
to indicate this form of inflammation, although recognizing another form 
of croup, the spasmodic or catarrhal, in which no pseudo-membrane 
occurs. 

Etiology. — Wherever diphtheria prevails as an endemic or epidemic, 
it is well known that a large majority of the cases of membranous croup 
are local manifestations of this disease, and this inflammation is there- 
fore in such localities commonly designated diphtheritic croup. Physi- 
cians have endeavored to discriminate between croup clue to diphtheria 
and that from other causes; but whatever the cause, the anatomical 
characters, the clinical history, and the required treatment are so nearly 
identical that attempts to differentiate the disease when produced by 
other agencies than diphtheria from that due to diphtheria, have proved 
futile and unsatisfactory in localities where diphtheria occurs, except in 
a few instances, as, for example, when croup has been manifestly caused 
by swallowing or inhaling some irritating agent. 

Inflammation of the laryngeal and tracheal surface, whatever its 
cause, whenever it reaches a certain grade of severity, may be attended 
by the exudation of fibrin and the formation of a pseudo-membrane, but 
such a result more frequently occurs in the inflammation caused by 
diphtheria than in that produced by other agencies. In diphtheria a 
moderate laryngo-tracheitis is attended by the pseudo-membranous 
formation. 

The percentage of cases of diphtheria in which the larynx becomes 
implicated and croup occurs, varies in different epidemics and in dif- 
ferent seasons and localities. In epidemics of a mild type, the cases 
appear to be fewer in which the larynx is involved than in epidemics 
of a severe form. In New York the percentage is large. From De- 
cember 1, 1875, to July, 1878, I preserved records of all the cases of 
diphtheria which came under my notice. The number was 104, and in 
twenty -five of these, or about one in four, croup occurred, producing the 
usual obstructive symptoms, and constituting the chief source of danger. 
During the two and a half years embraced in these statistics the disease 
was usually severe. In the last five years amelioration has occurred 
in the type of diphtheria in this city, and the proportion of croup cases 
has not been so large. 



568 



MEMBRANOUS CROUP. 



So commonly is membranous croup, when occurring in a locality 
•where diphtheria is endemic or epidemic, a local manifestation of diph- 
theria, that physicians in such localities come to regard every case of 
this disease of the larynx as produced by the diphtheritic poison. In 
New York physicians scarcely recognize any other form of membranous 
croup. It is well, therefore, briefly to recall the evidences that croup 
in a certain proportion of cases results from other causes than diph- 
theria. The occurrence of croup in localities where diphtheria is un- 
known, of course, indicates the operation of some other agency than the 
diphtheritic poison. Thus, in 1842, before diphtheria was established 
in this country, Dr. John Ware, of Boston, published his well-known 
paper on croup, and in 74 of the 75 cases embraced in his statistics the 
membranous exudation was present upon the faucial surface. The sta- 
tistics relating to the introduction of diphtheria into New York City, 
and the recorded death statistics of this city, have been annually pub- 
lished, and each year more or fewer deaths from croup have been re- 
ported. The first death from diphtheria in this century, within the city 
limits, certified by a physician, was that of a German woman, at 638 
Hudson Street, on February 15, 1852. Two other fatal cases occurred 
in 1857, and since then the deaths from croup and diphtheria have been 
as shown in the following table : 

Tear. 

1867 . 

1868 . 

1869 . 

1870 . 

1871 . 

1872 . 

1873 . 

1874 . 

1875 . 

Since 1875 weekly bulletins were issued, instead of the annual reports. 

Thus, in the first years after the introduction of diphtheria, the 
deaths assigned to croup so greatly outnumbered those of diphtheria, as 
in 1858, when five died of diphtheria and four hundred and seventy- 
eight of croup, that it is evident that most of the cases of croup in those 
years were attributable to other causes than diphtheria. Since, as we 
have stated, any inflammation of the surface of the larynx and trachea; 
if sufficiently intense, may produce a pseudo-membrane, croup may 
occur as a primary disease, and as a complication of various maladies. 
According to my observations in New York City, the chief causes of 
croup, arranged in the order of frequency, would be about as follows : 
diphtheria, "taking cold," measles, pertussis, scarlatina, typhoid fever, 
irritating inhalations. I have, elsewhere, related cases of scarlet fever 
of severe type, in which a thin film of pseudo-membrane was found upon 
the surface of the larynx and trachea, and there was no other lesion to 
indicate that diphtheria had supervened. The croup was, to all appear- 
ances, caused by the scarlatinous and not the diphtheritic poison. The 
following was a case in which croup was apparently idiopathic, and pro- 



Year 


Croup. 


Diphtheria. 


1858 . 


. . 478 


5 


1859 . 


. 622 


53 


1860 . 


. 599 


422 


1861 . 


. 460 


453 


1862 . 


. 685 


594 


1863 . 


. 908 


981 


1864 . 


. 754 


781 


1865 . 


. 449 


534 


1866 . 


. 368 


435 



Croup. 


Diphtheria. 


338 


251 


342 


276 


483 


328 


421 


308 


466 


238 


675 


446 


732 


1151 


594 


1665 


758 


2329 



ETIOLOGY. 569 

duced by that common cause of inflammations of mucous surfaces, to 
wit, exposure to sudden atmospheric changes : 

Case. — At midnight, on October 22, 1884, I was summoned to a child 
aged 25 months, who had been in the street till nearly nightfall, when the 
weather suddenly became much cooler, and he was brought home. At 
11.45 p. m. he awoke with a harsh voice and croupy cough so as to alarm 
the family. I found the axillary temperature normal, but the fauces were 
injected, and the diagnosis was made of spasmodic or catarrhal croup. 
Emesis was produced by syrup of ipecacuanha ; the croup kettle, and a 
mixture of potassium chlorate and ammonium chloride were ordered. 

On the following day he walked around the room and seemed better, 
but the inhalation of the vapor of lime from the croup kettle was con- 
tinued. At 7 p. m. the symptoms became aggravated, the cough was fre- 
quent and hoarse, temperature (axillary) 10(H°, pulse 120, and respiration 
noisy. At my visit the post-clavicular, supra-sternal, infra-mammary, 
and epigastric regions were depressed in each inspiration, though only to 
a moderate degree ; face flushed, fauces injected but without pseudo-mem- 
brane. The aspect was now more serious on account of the increasing dys- 
pnoea. The pulse was strong, and no pseudo-membrane was visible ; the 
temperature in the groin was scarcely 100°. Emesis had been produced 
before my arrival, and in the matter vomited was a pseudo-membrane 
with ragged edges, and about one-half an inch in length ; examined within 
an hour subsequently under the microscope, it was found to consist of 
fibrillar, evidently fibrinous, some of them wavy, and inclosing many pus- 
cells. Ten grains of calomel were placed on the tongue, and inhalations of 
the following were almost constantly employed by the steam atomizer : 

R. — Liq. potassae 3 ij. 

Aq. calcis ^ x ij- — Misce. 

On the following day the respiration was easier, and within twenty 
hours the patient had so far convalesced as to be out of danger. There 
had been no case of diphtheria in the house, nor recently, so far as I could 
learn, in the immediate neighborhood. 

That this w T as a local disease, non-specific, and quite distinct from 
the croup of diphtheria, cannot, I think, be doubted. 

In considering the etiology of croup, and recognizing diphtheria as 
by far its most common cause, wherever the latter disease prevails, an 
interesting theory is suggested, to which Heubner alludes, who affirms 
that inflammations, even with the characteristic membranous exudation, 
may be set up without the micrococci of diphtheria and then inoculation 
by micrococci occur, and "induce the general disease." 1 The point 
alluded to is that inflammations arising from other causes than diphtheria 
now and then become intensified, and rendered more protracted and dan- 
gerous by the reception of the diphtheritic virus after the inflammations 
are established. In support of this opinion it is well known by all who 
have had much experience with diphtheria, that those surfaces are 
prone to be attacked by the specific inflammation that are already irri- 

1 "Die experimentelle Diphtheria," Leipzig, 1883, quoted in Ziegler's Pathol. 
Anat., part, ii., paragraph 444, Wm. Wood & Co., 1884. 



570 MEMBRANOUS CROUP. 

tated or inflamed when diphtheria is contracted. Hence the occurrence 
of the pseudo-membrane on recent wounds, upon the eyelids in cases of 
catarrhal conjunctivitis, upon the uterine surface after parturition, and. 
upon the laryngeal, tracheal, and bronchial surfaces, if they are already 
inflamed as in measles. 

Scarlatina is so often complicated by diphtheria that there seems to 
be a close affinity between the two diseases. It is a very common ob- 
servation in New York City that scarlet fever continues two or three 
days, in its usual form, when the symptoms become suddenly aggra- 
vated and the aspect of the disease more severe. On inspecting the 
fauces a pseudo-membrane is discovered covering this region, and it 
probably appears also upon the nasal surface. Although severe scarla- 
tinous inflammation may cause a fibrinous exudation, yet that diph- 
theria has supervened upon scarlet fever in a considerable proportion 
of cases which have the above history cannot, I think, be doubted. In 
a few instances in my practice (four) the fact that scarlet fever was com- 
plicated by true diphtheria, and the scarlatinous inflammations, first in 
order, were intensified by the presence and influence of the diphtheritic 
poison, was shown by the occurrence of diphtheria without scarlet fever 
in other members of the family. 

In accordance with the above law, we may assume that a child who 
has laryngo-tracheitis, so common from taking cold and manifested by 
cough and hoarseness, is more prone to have diphtheritic croup than is 
one whose air-passages are in their normal state when diphtheria com- 
mences. A supposed error of diagnosis is often made by physicians, 
always to their discredit, who diagnosticate catarrhal laryngitis, but find, 
after two or three days, that their patients really have diphtheritic 
croup. A considerable number of such instances have come to my 
notice, always with the ill-will of families toward their physicians. 
Now it seems to me that in many of these cases the physicians have 
been right in their first diagnosis, and diphtheritic croup supervened on 
the catarrhal inflammation. 

Another point relating to the etiology of diphtheritic croup requires 
notice. Many physicians, who have had ample opportunities to ob- 
serve diphtheria, believe that the common way in which diphtheritic 
croup begins is as follows : The faucial or nasal surface is first affected, 
becoming covered by the pellicular exudation, and 'during inspiration 
particles of the pseudo-membrane, containing the specific principle, being 
detached, lodge in the larynx. At the point of inoculation the specific 
inflammation arises and extends. This may be the manner in which 
the croup of diphtheria begins in certain cases, but it certainly does 
not apply to a considerable number of patients. Thus both the faucial 
and nasal pseudo-membranes may be treated every second or third hour 
from the time of their formation w T ith the best disinfectants which we 
possess, so as to destroy all the micrococci in them and render them an 
inert mass, and yet croup not infrequently occurs during the progress 
of the case. Again, in certain cases croup begins at the commence- 
ment of the diphtheritic attack. The laryngitis commences as early as 
the pharyngitis, and therefore does not result from it. Sometimes the 
inflammation of the air-passages is from the first the predominant 



ANATOMICAL CHARACTERS. 571 

lesion, the pharyngitis being subordinate or even trivial. Thus a boy 
of two years ten months, whom I attended, died of croup lasting about 
four days. He lived in the suburbs of the city, where the houses were 
scattered, and where there had been no recent diphtheria. The attack 
began with hoarseness, which gradually increased to a fatal obstruction 
in the air-passages. Close and repeated inspection of the fauces re- 
vealed only redness and some swelling of the parts that were visible, 
and the symptoms indicated but slight coryza. The diphtheritic nature 
of the disease was rendered certain by the occurrence of diphtheria in 
its usual form, in the two nurses immediately after the death of the 
child. In this case croup began at the beginning of the sickness, and 
it is evident from the history and the lesions that the contagium was 
not transferred to the larynx from any of the other surfaces. In view 
of the number of such cases, I see no propriety in assigning to diphthe- 
ritic croup a mode of origin different from that of other diphtheritic 
inflammations. But the possibility, and perhaps probability, in some 
instances of an auto-infection we will not deny. 

Anatomical Characters. — It is important to acquaint ourselves 
with the anatomical characters of croup, especially with the nature of 
the pseudo-membrane, that we may know what measures to employ in 
order to remove it and prevent, as far as possible, the laryngeal stenosis 
from which so many perish. The surface of the larynx, trachea, and, 
in severe cases, that of the bronchial tubes, is hyperaemic and swollen, 
and the inflammatory action involves more or less the submucous con- 
nective tissue, causing infiltration or oedema. The relation of the exu- 
dation to the mucous surface varies according to the kind of epithelium 
present. Where the epithelium is of the flat or squamous variety, the 
fibrinous exudation from the bloodvessels is poured out around the epi- 
thelial cells, which perish. If the inflammation extend more deeply, 
the underlying connective tissue is also embraced in the coagulation and 
perishes. Prof. Ziegler, of Tubingen, who has made repeated micro- 
scopic examinations of the pseudo-membrane, says : "It sometimes 
happens that the dead epithelial cells become saturated with the exuded 
liquid and then pass into a peculiar condition of rigidity akin to coagu- 
lation. The seat of this change appears to the naked eye as a dull, 
raised, grayish patch surrounded by red and swollen mucous membrane. 
The exudation is rich in albumen and the transformed cells take on the 
appearance of a kind of coarse meshwork, almost or altogether devoid 
of nuclei." This is superficial diphtheritis, and Prof. Ziegler next 
describes deep or parenchymatous diphtheritis as follows: "It is char- 
acterized by the coagulation, not merely of the epithelium, but also of 
the underlying connective tissue. The affected patch is swollen and 
assumes a whitish or grayish tint, the discoloration extending through 
the epithelium to the connective tissue structures. The epithelium in 
some cases is lost altogether, and then the diphtheritic patch consists of 
dead connective tissue only. . . . The dead tissue is separated 
from the living by a zone of cellular inflammation. Fibrinous filaments 
are seen here and there through the mass. The lymphatics in the 
neighborhood contain coagula and leucocytes." 

Squamous epithelium covers the nostrils, buccal cavity, fauces, the 



672 MEMBRANOUS CROUP. 

larynx upon and above the superior vocal cord, with the exception of its 
anterior aspect. The pseudo-membrane, therefore, upon all these sur- 
faces lined with this form of epithelium consists of the exudate from the 
blood which surrounds and permeates the epithelium, or epithelium and 
subjacent connective tissue. These two distinct elements, that poured 
out from the bloodvessels and the normal tissue of the mucous surface 
now dead, incorporated in one mass, therefore, constitute the pseudo- 
membrane. Its intimate relation with the surrounding living tissue is 
such that we cannot detach it without lacerating the latter and causing 
bleeding. 

The anterior aspect of the larynx from the middle of the epiglottis 
downward, all that part of the larynx below the superior vocal cord, 
the entire trachea, and the bronchial tubes, are lined by columnar epi- 
thelium. Whenever this variety of epithelium is present, the exudate 
from the blood does not become incorporated with the mucous mem- 
brane, but escapes to the surface and coagulates in a layer over it. It 
is, therefore, loosely adherent to the underlying tissues, being attached 
to it by some fibrinous threads, and when it is peeled off, the hypersemic 
and swollen mucous membrane is seen underneath in its entirety, unless, 
as is commonly the case, a considerable part of its epithelium has been 
shed and been expectorated. The loose attachment of the pseudo-mem- 
brane in the trachea and bronchial tubes is of the greatest significance 
in its relation to tracheotomy. 

In this connection it is proper to call attention to the confusion which 
occurs in the use of the terms diphtheritic and croupous, as employed by 
pathologists on the one hand, and clinical observers or practitioners on 
the other. Pathologists, following Virchow, designate the inflammation 
diphtheritic when the epithelium and underlying tissues remaining in 
situ are blended with the exudate and become a part of the pseudo- 
membrane, whatever may be the cause of the inflammation, and they 
designate the inflammation croupous, whatever its cause, when the exu- 
date escapes to the surface of the mucous membrane, as in the trachea 
and bronchial tubes, and coagulates upon it. Therefore, in all cases of 
pseudo-membranous inflammation of the air-passages, even that due to 
" taking cold," or to inhalation of an irritating vapor, they term the 
laryngitis diphtheritic, since in the larynx the exudate is incorporated 
with the mucous membrane, while the pseudo-membranous tracheitis or 
bronchitis in the same patient is termed croupous, since the exudate lies 
upon the surface. Practitioners, on the other hand, apply the term 
diphtheritic to all inflammations which occur as local manifestations of 
the specific disease, diphtheria, and only to such inflammations, what- 
ever may be their form, whether pseudo-membranous or catarrhal. 

The epithelial cells embraced in the pseudo-membrane undergo a his- 
tological change. We have stated Ziegler's remark that they are per- 
meated by the exudate of the blood. Cornil and Ranvier say, " Wagner 
admits the fibrinous degeneration of the cells. . . . We have veri- 
fied the description given by Wagner, but we would conclude that the 
cells are filled with a material w T hich approaches mucin rather than 
fibrin." In the first week, the pseudo -membrane forms more rapidly, 
and is usually thicker and more extended, producing dyspnoea more 



SYMPTOMS. 573 

quickly than when it forms in the declining stage of the disease. If 
the membrane be detached by the forcible coughing of the patient, it is 
usually quickly reproduced unless the diphtheria be in its advanced 
stage and abating. If the croup continue from four to six days, the 
pseudo-membrane begins to soften from commencing decomposition and 
to disintegrate. The minute fibres which attach it to the membrane 
give way, and in favorable cases by the effort of coughing or vomiting 
it is thrown off. Separation is aided by the muco-pus which collects 
underneath. 

Symptoms. — Whenever croup is one of the local manifestations of 
diphtheria, such general or constitutional symptoms are present as per- 
tain to this blood disease, such as febrile movement, anorexia, thirst, 
and progressive loss of flesh and strength. The temperature in the 
commencement in croup from this cause is usually higher than at an 
advanced period, unless some complication occur, as pneumonia, which 
increases the heat of the system. The temperature is not, however, in 
the beginning, ordinarily above 103° or 104°, and, as the croup con- 
tinues, and the systemic blood-poisoning becomes mo^re marked, the 
temperature usually falls, so that, even in the gravest cases, it is often 
at or below 100°. Most patients also have those inflammations which 
commonly attend diphtheria, i. e., pharyngitis and more or less coryza, 
but they are relatively unimportant in comparison with the croup, for, 
unlike the croup, they do not in themselves involve immediate danger to 
life. 

Croup commonly begins gradually and insidiously, revealed at first 
to the physician by hoarseness or huskiness of the voice, and a hoarse 
or harsh cousdi. Both voice and coudi are feeble, lacking the fulness 
and sonorousness present in spasmodic laryngitis. In grave cases 
approaching a fatal termination, the voice becomes more and more 
indistinct, and finally is suppressed. The cough, also, which in the 
beginning of the croup was strong and expulsive, becomes feeble and 
ineffectual, and less frequent as the fatal result draws near. 

The amount of sputum varies considerably in different cases. If the 
inflammation extend no further downward than the trachea, it is scanty, 
but if there be coexisting bronchitis, it is more abundant, consisting of 
muco-pus with occasional flakes of pseudo-membrane. By vomiting a 
larger quantity is expelled than by the cough. Occasionally masses of 
pseudo-membrane of considerable size are expectorated, even moulds of 
some part of the respiratory passage, always with great temporary relief 
to the patient. A pseudo-membrane of considerable thickness and extent 
obstructs the expectoration of muco-pus, which collecting in the lower 
part of the trachea and in the bronchial tubes, greatly increases the dys- 
pnoea. The respiration is somewhat more frequent than in health, but 
it is not notably increased except when bronchitis or broncho-pneumonia 
is present. At an advanced stage, when stupor supervenes from non- 
oxygenation of the blood, the respiration may be slower than in health. 

Croup in its commencement and in the active period of diphtheria 
without treatment almost never remains stationary or abates. Little by 
little or often quite rapidly, the laryngeal stenosis increases, and soon 
the patient begins to experience the want of air. He becomes restless, 



574 MEMBRANOUS CROUP.' 

has an anxious expression of the face, seeks change of position, reaching 
out his arms to the nurse or mother to obtain relief. In some patients 
only a few hours elapse and in others a day or more of gradual increase 
in the obstruction, when it becomes evident that death must soon occur 
unless relief be afforded. In this stage the post-clavicular, infraclavi- 
cular, suprasternal, and inframammary regions are depressed during in- 
spiration, and the larynx is drawn with each inspiratory act toward the 
sternum. While there is constant suffering, there are also occasionally 
most distressing attacks of dyspnoea attended by an increase in the 
lividity of the features and extremities, which now have an habitual 
dusky pallor. Sometimes these attacks are perhaps due to the doubling 
of a detached end of the pseudo-membrane on itself, or perhaps to a 
movement of the muco-pus by which bronchial tubes are occluded. 
With the ear applied over the larynx or upper part of the sternum, a 
loud rhonchus is heard both on inspiration and expiration, produced by 
the passage of the air over the obstruction, and obscuring to a great 
extent the other sounds. Moist bronchial rales are also common. 

Those who recover from membranous croup without tracheotomy, 
and by the use of inhalations, and thus far they constitute only a small 
minority, usually improve gradually, the obstruction diminishing by 
softening and detaching of portions of the pseudo-membrane, the cough 
becoming looser and the voice less hoarse. After the detachment of 
the pseudo-membrane, several days elapse before the thickening and 
infiltration of the mucous membrane disappear and the epithelial cells 
are restored. 

Diagnosis. — Catarrhal laryngitis with an unusual amount of thick- 
ening and infiltration of the mucous membrane and the underlying con- 
nective tissue, so as to produce stenosis and obstruct respiration, may 
be mistaken for pseudo-membranous laryngitis. In the New York 
Foundling Asylum, two children have at different times died with the 
symptoms of membranous laryngitis, and the obstruction was found to 
be clue entirely to the thickening and infiltration of the mucous and sub- 
mucous tissues of the larynx by newly formed corpuscular elements. Of 
course, death from catarrhal laryngitis is rare, but that this disease may 
produce such an amount of laryngeal stenosis as to cause even fatal dys- 
pnoea, like that from the presence of pseudo-membrane, those two cases 
show. In most instances, the diagnosis of membranous laryngitis from 
catarrhal laryngitis is easy, by the presence of patches of pseudo-mem- 
brane on the fauces, or by the history of the case, which evidently points 
to diphtheria as the cause. I have elsewhere alluded to a child in my 
practice who died with the symptoms of acute laryngeal stenosis, with- 
out any pseudo-membrane upon visible parts, and with only a moderate 
pharyngitis. This case, which might have passed as one of catarrhal 
laryngitis, accompanied' by an unusual amount of cellular and serous 
infiltration, as there was no known diphtheria in the vicinity, was really 
due to diphtheria, and was a local manifestation of that disease, for 
immediately after the death of the patient the two nurses had unequiv- 
ocal symptoms of diphtheria. The difficulty in using the laryngoscope 
in young children is such, when their fauces are swollen, that it has not 
heretofore aided much in the differential diagnosis of the various forms 



PROGNOSIS. 575 

of acute laryngeal stenosis in young children, at least when employed 
by the general practitioner. 

Prognosis. — The mortality from croup obviously depends to a great 
extent on the prevalence and the t} T pe of diphtheria. From what has 
been stated above, it follows that croup is more frequent and more fetal 
in a grave form of diphtheria than in mild epidemics with a less degree 
of blood-poisoning. In New York City, during the fifteen years ending 
with 1878, the percentage of recoveries was very small, both under 
medicinal treatment and tracheotomy. During this long period, sur- 
geons, not saving more than three to five per cent, of their cases by 
tracheotomy, performed this operation reluctantly. But since 1878 
the percentage Qf recoveries after tracheotomy has been much greater. 
The mortality from croup is greater the younger the patient ; for the 
younger the child, the less the diameter of the air-passages, and the 
more quickly laryngeal stenosis results. The younger the child, also, 
the more difficult is the use of the proper remedies, and the less the 
time for their use before fatal dyspnoea occurs. We have already said 
that croup appearing in the declining stage of diphtheria is less severe 
and more easily controlled or cured than when it occurs in the com- 
mencement of diphtheria. Much depends, also, upon whether the 
physician is summoned at the very beginning of the croup, and appro- 
priate remedies are early and persistently employed. In many in- 
stances the friends do not take alarm, and the physician is not sum- 
moned till the disease is well under headway, and there is not the requi- 
site time for the action of inhalations. Obviously, also, croup, beyond 
all other diseases, requires faithful and intelligent nurses, for without the 
cooperation of such nurses night and day, in the care of the patient, the 
most judicious measures are often rendered inefficient. 

Exact statistics are lacking to show what proportion of cases of croup 
recover by strictly medicinal treatment. If we regard as incipient 
croup those cases in which the voice becomes hoarse or harsh, but no 
dyspnoea occurs, and the lungs are fully and normally inflamed, a con- 
siderable number, I think, more than fifty per cent, in my practice, 
recover. There may be in these cases a catarrhal laryngitis, or there 
may be a thin film of pseudo-membrane upon the laryngeal surface, not 
sufficient to embarrass respiration. Slight laryngitis, therefore, occur- 
ring in the course of diphtheria, unaccompanied by any increase in tem- 
perature, or change in the freedom or rhythm of respiration, and whose 
only symptom is a huskiness of voice, if treated early and properly by 
inhalations, passes off in a few days in a large proportion of cases. It 
possesses little importance except that it might be the initial stage of 
croup if neglected. It is obviously improper to consider this trivial 
form of laryngitis as membranous croup, although by neglect it might 
become such. In the statistics of croup, those cases only should be 
included in which the symptoms are so pronounced that it is evident 
that more or less laryngeal stenosis is present, although there may as 
yet be no marked dyspnoea. 

In determining the percentage of recoveries in croup, it is proper to 
arrange cases in two groups: 1st, cases which have received only medi- 
cinal treatment; 2d, cases in which tracheotomy has been performed. 



576 MEMBRANOUS CROUP. 

Having been in almost continuous practice since diphtheria began in 
New York, in a section of the city where this disease has always been 
prevalent, and having witnessed all kinds of treatment — that by emetics, 
by depletion, by stimulation, by inhalation and insufflation — it is my 
opinion that not more than one in eight has recovered by medicinal 
treatment in this long period, of cases of croup which began in the first 
week of diphtheria, and in which the symptoms were so pronounced as 
to indicate more or less laryngeal stenosis. The exudation in the first 
week of diphtheria, or in its active period, occurs so rapidly, and in such 
large quantity, that no one of the medicinal agents or modes of treat- 
ment, which physicians commonly prescribe, is sufficiently prompt in its 
action to prevent the formation of the pseudo-membrane to an extent 
that soon endangers life. I allude to what has hitherto been the result. 

Perhaps we may yet discover a mode of treatment that more effectu- 
ally controls the formation of pseudo-membranes. 

Croup occurring in the second or third week of diphtheria, since it is 
attended by less abundant and less rapid exudation than when it occurs 
during the acute stage, can be more successfully treated under the per- 
severing use of solvent inhalations, and, according to my observations, a 
larger proportion than one in eight, perhaps one in three, recovers by 
the early and continuous or almost continuous use of inhalations. 

Still the mortality is so large, and the suffering so great in croup, at 
whatever stage of diphtheria it occurs, that we cannot rely on the slow 
action of medicines or inhalations, and surgical treatment is in most in- 
stances required to diminish the suffering, and afford the best chances for 
saving life. Tubing the larynx, to which we will allude hereafter, has 
been so seldom performed, and the statistics of it are so meagre, that 
we are unable to state what proportion of patients may be saved by it. 
I have twice observed in the New York Foundling Asylum prompt relief 
from tubage, when the dyspnoea was so great as to threaten immediate 
death. In one of the two patients the relief was temporary, and in the 
other permanent. If the obstruction were confined to the larynx or 
larynx and upper part of the trachea, tubage would, I think, come into 
general use as a substitute for tracheotomy, but, unfortunately, it fails 
to give relief and save life in those many cases in which the obstruction 
extends throughout the trachea and into the bronchi. The statistics of 
tracheotomy, on the other hand, are abundant, and we are enabled 
therefore to determine to what extent it can rescue the victims of this 
disease from impending death. The American Journal of Obstetrics 
for May, 1868, gives the results of tracheotomy performed by Drs. 
Jacobi, Krackowizer, and Yoss as follows : 



Jacobi, Kiackowizer, and Yoss . . . 166 
J. H. Ripley, N". Y. Med. Record, 1880 . . 56 
Parisian Children's Hosp., 1851-1875 (Tenne) 4663 
Bethanien in Berlin, 1861-1872 (Bartels) . 330 
Berliner Chirurg. Klinik, 1870-1876 (Kronlein) 504 
St. AnnenspitafWien (Monti) . . . .210 
Table of Monti from various sources . . 2608 
Hofmohl's statistics 3760 



Recove- 


Deaths. 


Per cent, of 


ries. 




recoveries. 


39 


127 


— 


16 


— 


— 


— 


— 


24 


103 


— 


31.2 


147 


— 


29 


— 


— 


33 








25 


— 


— 


27 



PROGNOSIS. 



i i 



Cases. 

Raster's statistics 1556 

0. Hospital, Trousseau, Paris, during 1883 (per 

Dr. L. Enfance) 359 

Clinic of the Zurich Kantonspitals, under Rose 
and F. Kronlein, 1868, March, 1882 (11 under 

2 years, 1 of 8 months) 238 

Deutsche Zeitschrift fur Chirurg., 1882, Bd. 

xvii. (H. Lindner) 101 

Statistik der Tracheotomie per Croup, Deutsche 
Chirurger Lieferung, 37 Stuttgard, 1880, by 
Kuhn .....'... 277 
Hopital des Enfants Malad., Paris, 1850-1857 . 389 
Hopital des Enfants Malad., Paris, 1860-1867 . 813 
Trousseau, according to Kuhn .... 466 
Guersant (Sedillot), Med. Oper., ii. page 480 . 171 
Barthef, Hospital St. Eugenie, 1855-1868 . 573 

Cases in the Parisian Hospitals and in the Pro- 
vinces, Fascher et Bricheteau . . . 1011 
Eoser (Lissard), C. C, 1854-1861 ... 42 



TThde, Archiv f. Klin. Chir. 1869, 1820-1869 . 
Max Muller (Langenb. Arch. f. Klin. Chir. vii.) 
Bardenheuer (Coiner Biirgerhospitals, 1875-1876) 



Recove- Deaths, 
ries. 



Krankenhause Bethanien, 1873, and following (1 
Settegast) ....... 

Billroth, Chirurg. Klinik Wien., 1871-1876 

lleisz, Bronchotomiens Indicat., 1858 

TVansher (Copenhagener Kommuni Hospitals, Sept. 
1863, Dec. 1876) 



81 

45 

129 

375 
18 
17 

400 



244 



152 



115 



92 



125 
86 

208 

126 
36 

160 



19 — 

Operations. B.ecov< 



21 
15 
46 

119 
1 
5 

170 



Per cent, of 
recoveries. 

32 
32 



— 3' 



22 

25 
21 
28 

25 
45.4 

Per cent, of 
recoveries. 

25 
33 
35.6 

31.75 



42.5 



The result of tracheotomy in infants is much less favorable than in 
older children. Dr. G-ustav Chagin 1 has published the statistics of 
cases in- infancy. These cases, 977, occurred since 1874; and of this 
number, 832, or 85 per cent., died. In the Copenhagener Kommuni 
Hospital, in which, as stated above, there was the remarkably good 
general result of 170 recoveries in 400 tracheotomies, only 5 per cent, 
recovered of children under one year ; of 76 operated on between the 
ages of one and two years$ 22 recovered, or 29 per cent. ; while of 296 
operated on between the ages of two and ten years, 146 recovered, or 
49.3 per cent. In the Krankenhause Bethanien, the results of trache- 
otomy from the beginning of 1861 to the close of 1876, tabulated ac- 
cording to the age, were as follows (H. Settegast) : 



Age. 










Tracheotomies. 


Recovered. 


Per cent 


2 to 3 years 93 


22 


23.65 


3 " 4 " 












165 


47 


28.45 


4 » 5 " 












175 


54 


30.85 


5 " 6 " 












107 


39 


35.45 


6 " 7 " 












90 


34 


37.77 


7 " 8 " 












59 


17 


38.86 


8 " 9 " 












24 


11 


45.83 


9 "10 " 












15 


6 


40.00 



The statistics show that the older the patient upon whom tracheotomy 
is performed, other things being equal, the greater the percentage of 



1 Archiv fur Kinderheilkunde, Bd. iv. 
37 



578 MEMBRANOUS CROUP. 

recoveries. Prof. Abraham Jacobi has probably performed tracheotomy 
for croup in as many cases as any other physician or surgeon in this 
country, not fewer, he thinks, than 400 times. His opinion corresponds 
with the common belief that, during the last five years, the percentage 
of recoveries after tracheotomy, in New York City, has been much 
larger than previously, and the operation is performed more frequently 
by the attending physician than formerly. The result of tracheotomy 
during a long series of years, ending with 1878 or 1879, was so unfav- 
orable, on account of the type of the disease, that Dr. Jacobi thinks, in 
the aggregate of his cases of tracheotomy since 1858, only about 12 per 
cent, recovered. 

Although at present in this city the percentage of recoveries after 
tracheotomy is much larger than formerly, yet the statistics of some of 
the prominent physicians and surgeons show nearly as large a propor- 
tion of deaths as in former years, probably because the operation has 
been deferred till the patients were nearly moribund. Thus, one sur- 
geon records only 4 recoveries in 21 operations during the last three or 
four years, and a physician of large experience, connected with one of 
the institutions where children are treated, has been equally unsuccess- 
ful in his tracheotomies, but he has operated only w T hen the dyspnoea 
was extreme, and death momentarily expected. Earlier operation 
might have given better results. 

The statistics of recent tracheotomies, which seem to me to indicate 
most accurately the results of this operation when skilfully performed, 
and not at too late a stage in the type of diphtheria now prevailing in 
this city, I have obtained from Drs. J. H. Ripley and Fred. Lange. 
The operations embraced in their statistics were performed since Jan- 
uary 1, 1879, with the following result : 

Tracheotomies. Died. Becovered. Per cent, of recoveries. 

66 44 22 331 

These surgeons do not select cases for the operation, but they operate 
on nearly every patient with croup, to whom they are summoned, pro- 
vided that death seems inevitable without tracheotomy. They operate 
even if serious complications be present, as nephritis or pneumonia, or 
the blood be profoundly poisoned. With them t the inducement to 
operate is sufficient if tracheotomy diminish the suffering, or increase 
the chances or recovery in however trifling a degree. Inasmuch, there- 
fore, as they do not select cases, so good a result is noteworthy. 

Some physicians in this city make greater discrimination in cases, and 
do not operate if the condition of the patient be such that death will in 
all probability occur after tracheotomy. They do not, therefore, advise 
the operation, if the patient have profound blood-poisoning or severe local 
disease elsewhere than in the air-passages. Such physicians by the early 
performance of tracheotomy, and by careful attention to the after-treat- 
ment, making frequent visits and supervising the details of the manage- 
ment, furnish more favorable statistics of the operation than those pub- 
lished above. Thus, Dr. A. R. Robinson, who carefully considers the 
indications and contraindications of tracheotomy, who operates early, 



PREVENTIVE TREATMENT. 579 

does not insert the canula until all loose muco-pus and shreds of pseudo- 
membrane are expelled by the cough from the trachea and bronchial tubes, 
and who supervises by frequent visits the after-management, has saved 
since 1880 eleven in thirteen consecutive cases of undoubted membranous 
croup. It is seen from the above statistics that we can claim for trache- 
otomy j udiciously performed, and at a sufficiently early stage, the cure 
of one in every three patients in the average. The statistics in Boston 
show that the results obtained in that city in hospital practice have been 
about the same as those in New York and in European cities. In an 
interesting paper on tracheotomy in croup, published in the Medical 
News, July 12, 1884, the writer says : "Tracheotomy for this disease 
has been performed one hundred and eighteen times at the Boston City 
Hospital during the past twenty years. Thirty-nine, or one in three, 
were successful. That the cases were not selected is shown by the fact 
that three patients died during the operation from shock and exhaustion, 
not from hemorrhage ; thirty-four died within twenty-four hours ; and 
fifty-six, or more than one-half of the fatal cases, within forty-eight hours. 
Four, if not five, of the successful cases were practically moribund at 
the time of the operation. . . . The ages of these patients ranged 
from nine months to forty-one years. The youngest to recover was 
eleven months ; the oldest sixteen years. Four aged two years and five 
aged three years got w^ell. Membrane was visible in the fauces or 
trachea in a large proportion of both the successful and unsuccessful 
cases. Its absence was noted in only three of each class. It need not 
be said that in every instance there was present severe, constant, and in- 
creasing dyspnoea, exhausting the strength and threatening suffocation." 

Preventive Treatment. — In attending a case of diphtheria the 
physician should notice at each visit whether the patient have any 
hoarseness or other signs indicating implication of the larynx, since, if 
the danger be recognized at its inception, it may perchance be averted. 
Ineffectual as inhalations may be for fully declared croup, we have seen 
in speaking of the prognosis that experience fully justifies the belief 
that they are sufficient in a large proportion of cases to relieve that de- 
gree of laryngitis which is indicated by simple hoarseness, and which if 
it continue might eventuate in serious obstructive disease. If the physi- 
cian observe such symptoms, he should immediately recommend that the 
air in the apartment be kept moist by the croup kettle or pans of hot 
water over the fire, into each of which a lump of lime is placed. I fre- 
quently surround the bed with a tent made with a clothes-horse, over 
which blankets are thrown, and place the croup kettle underneath. 
Frequently stirring the water in the kettle adds to its efficiency. I 
prefer, however, in most instances, to employ the steam atomizer either 
with or without the croup kettle. It should be so constructed that it 
throws a heavy spray of rather turbid lime-water, and should be almost 
continuously used as long as the premonitory symptoms of croup con- 
tinue. It obviates the necessity of heating the* apartment, which in hot 
weather is very uncomfortable. 

It is proper, in this connection, to consider which is the most efficient 
and the best agent for inhalation in croup. Have we an agent that can 
be safely used, which will prevent, when inhaled, the formation of the 



580 MEMBRANOUS CROUP 

pseudo-membrane, or which will dissolve it when it has already formed? 
The agents which have been most employed for this purpose are lime- 
water, lactic acid, pepsin, and bromine. 

In selecting the one that is safest and most efficient, the important 
fact should be borne in mind that anything which irritates, so as to in- 
crease the inflammation of the mucous surface, is injurious. Whatever 
intensifies the inflammation, evidently augments the thickening and in- 
filtration of the mucous membrane, and increases the area as well as 
thickness of the pseudo-membrane. It is therefore harmful instead of 
beneficial. In my opinion the teachings of Bretonneau and Trousseau 
did immense harm in the fact that they brought into use agents far too 
irritating to the sensitive mucous surface. Since the pressing danger 
in croup arises from the obstruction produced by the pseudo-membrane, 
and by the thickening and infiltration of the mucous membrane under- 
neath, that agent is indicated, if it can be found, which loosens and dis- 
solves the pseudo-membrane, and at the same time tends to diminish or 
at least does not increase the inflammation of the underlying tissues by 
its irritating action. Alkalies exert a solvent action on fibrin and mucin, 
and as the pseudo-membrane consists of the exudate from the blood 
largely fibrinous, and of epithelium and connective tissue which have 
undergone degeneration into a substance resembling fibrin (Wagner) or 
perhaps mucin (Cornil and Ranvier), their employment seems to rest on 
a sound therapeutic basis. Lime-water slightly turbid, but not so turbid 
as to clog the point of the steam atomizer, and containing about one 
and a half per cent, of liqour potass^e, is probably as efficient and useful 
a solvent as any of the alkaline mixtures which have been commonly 
used. One and a half per cent, liquor potassse becomes about one per 
cent, when mixed with steam from the boiler. Dr. E. M. Moore, 1 of 
Rochester, recommends insufflation of sodium bicarbonate as an active 
solvent of the pseudo-membrane. It possesses this advantage, that it is 
but slightly irritating, so that it can be used in substance or w T ith but 
little dilution. For this reason it should be preferred to lime-water, 
which is in more common use. 

By the persistent and timely use of such inhalations as soon as 
hoarseness appears, croup can, in my opinion, be often prevented. But 
we all know how often, notwithstanding our best endeavors, croup oc- 
curring in the first week of diphtheria grows hourly worse. In these 
acute and rapid cases inhalations of the best agents which physicians 
have hitherto used, act too slowly to prevent the growth of the pseudo- 
membrane, and in a few hours it becomes painfully evident that some- 
thing more must be done or the life of the child is lost. In those many 
cases in which diphtheria is ushered in with croupous symptoms, and 
in which, within a few hours, laryngeal stenosis begins to occur, the 
experienced physician sees at a glance, often at his first visit, that inha- 
lations, however faithfully employed, will be inadequate, and that suffo- 
cation, the most painful of all modes of death, will be inevitable, unless 
other and energetic measures are used. 

On the other hand, in the milder forms of croup, in which the exuda- 

1 Transactions of the N". Y. Medical Association, 1885. 



PREVENTIVE TREATMENT. 581 

tion has but moderate thickness and forms slowly, inhalations are of the 
greatest service, and, aided by internal remedies, they not infrequently 
arrest the disease and save life. The following was such a case : M. J., 
a girl of two years and five months, took diphtheria on January 6, 1884. 
I first saw her on the 9th, when a considerable amount of pseudo mem- 
brane covered the fauces. The temperature was but moderately ele- 
vated, and a slight discharge occurred from the nostrils. Under the 
usual treatment the pharyngitis abated, and she seemed to be convales- 
cing until January 14th, when her respiration began to be noisy and 
embarrassed. On inspecting the fauces a pseudo-membrane was seen 
upon the aperture of the glottis, apparently dipping down into it. The 
steam atomizer was employed almost constantly, throwing a spray of 
lime-water with about one per cent, of liquor potassae. Each inspira- 
tion was accompanied by marked depression of the post-clavicular, epi- 
gastric, and inframammary regions, and the respiration was noisy and 
embarrassed till the 17th, when it began to improve, and the patient 
was soon out of danger. It will be observed that the croup commenced 
in the second week or in the declining stage of diphtheria. Had it been 
earlier, when the inflammation was more active, and the exudation 
more rapid, in all probability the patient would have perished unless 
saved by tracheotomy. The slowness of the exudative process afforded 
time for the action of solvent inhalations. Nearly at the same time that 
this case occurred, a patient in my practice, who had recovered from croup 
by tracheotomy, was seized with dyspnoea a month after the operation, 
when the opening had healed, and a flapping sound could be distinctly 
heard, produced probably by a pseudo-membrane, which was partially 
detached. This obstruction, which for a time apparently involved 
great danger from the dyspnoea which it caused, was removed by the 
third day under alkaline inhalations. In such cases, in which the 
inflammation is mild and the exudation at a standstill, or slow, the 
benefit from inhalations is most apparent. I am confident that one 
good result from alkaline inhalations is not fully appreciated by the 
profession ; I refer to the fact that they render the muco-pus, which 
collects in large quantity in the bronchial tubes, and is expectorated 
with difficulty, on account of its viscidity, and the obstacle above it, 
thinner and more easily expelled. 

Now that diphtheria has become so prevalent in this country, and so 
many children perish of the croup which it produces, it is to be hoped 
that some more efficient, and at the same time unirritating substance 
may be discovered for inhalation than those at present in use. 

Since my attention has been called to the fact, by Dr. Van Syckel, 
of New York, that trypsine, one of the digestive ferments secreted by 
the pancreas, is a rapid solvent of fibrin, he having observed its action 
in the laboratory of Prof. Kiihne, of Heidelberg, I have employed this 
agent in the usual form of diphtheria in several instances with such 
result as to encourage the hope that the solvent which we have so long 
needed has been found. I have never seen pseudo-membranes disap- 
pear from the fauces more rapidly than in cases in which the following 
mixture was applied, every half hour, with a large camel's-hair pencil, 



582 MEMBRANOUS CROUP. 

whether the good effect was due to the trypsine contained in the extract, 
or to the alkali, or to the combination of the two : 

Extracti pancreatis (Fairchild's) . . . zj. 

Sodii bicarbonat. ^iij. — Misce. 

Add one teaspoonful of this to six teaspoonfuls of water. 

Thus recently, in a child of about five years, a thick pseudo-mem- 
brane over each tonsil had disappeared by the third day, without appa- 
rently any irritating effect from the application. Mr. Fairchild has 
recently prepared trypsine in a liquid form, in order that its efficacy can 
be more readily and conveniently tested as a solvent for the membranes 
in croup ; and Dr. H. D. Chapin informs me that this liquid employed 
in spray quickly dissolved the pseudo-membrane in situ upon the larynx 
removed from an infant that perished from this disease. Additional 
clinical observations will soon determine the value of trypsine as a sol- 
vent, and whether, if it be a good solvent, it can be utilized as a spray. 
That it requires an alkaline medium for its activity renders it compat- 
ible with alkaline inhalations. 

Internal Treatment — Calomel. — This was long regarded as the 
most important internal remedy for membranous croup, as well as for 
diphtheritic exudations elsewhere than in the larynx. In the belief 
that it had a tendency to prevent the formation of pseudo-membranes, 
and aided in detaching and removing those already formed, it was in 
common use until about twenty-five years ago. It was sometimes pre- 
scribed for croup in large doses, but more frequently in doses of one- 
half, one, or one and a half grains, repeated every second or third hour, 
and often in combination with an opiate, as Dover's powder. However 
useful a remedy it may be when judiciously employed in croup, as well 
as in certain other diseases, it fell into disuse on account of its ill-advised 
employment in diseases which did not require it, its employment often 
to the extent of producing unpleasant and even dangerous symptoms. 
When diphtheria was established in this country, calomel was in a few 
years discarded by most physicians as a remedy for croup, on account 
of the growing belief that nearly all cases of this disease were local 
manifestations of diphtheria, and required less depressing and more 
sustaining measures than mercury. Moreover, it was easy to point 
out cases in the writings of such masters of the profession as Breton- 
neau and Trousseau, in which calomel was improperly employed, doing 
harm by causing not only severe salivation, but also gangrene. Never- 
theless cases occurred in those days which seemed to show that this 
agent properly employed is a potent and useful remedy for croup. One 
in the Astor House of New York attracted much attention. A child of 
about two years, stopping at this hotel, had pseudo-membranous laryngitis, 
with constant and increasing dyspnoea. Prominent physicians summoned 
to him expressed the opinion that he could not live, when, through the 
advice of a physician from an inland city, who was temporarily sojourn- 
ing in the hotel, twenty grains of calomel were placed on his tongue. 
From this time the dyspnoea began to abate, and the patient recovered. 

The medical journals from time to time contain reports of cases of 
croup in which calomel has apparently been beneficial. Dr. J. P. Klin- 



INTERNAL TREATMENT CALOMEL. 583 

gensmith, 1 of Blairsville, Pennsylvania, states that physicians in his 
locality prescribe calomel in large doses for croup, and with greater suc- 
cess than that achieved by other modes of treatment, and he relates 
three cases, showing the result in his own practice : 

Case. — A child aged 28 months took twenty grains of calomel placed 
on the tongue in the commencement of croup, and afterwards ten grains 
every hour till the third day when 720 grains had been taken. It was 
now discontinued, and on the sixth day the pseudo-membrane had disap- 
peared. Recovery was rapid, and without any untoward symptoms. 

Case. — The second patient, aged three and a half years, had been sick 
forty-eight hours, with a temperature of 1Q2° F. He had a croupy cough, 
and a pseudo-membranous exudation. Twenty grains of calomel were 
administered and afterwards ten grains every hour for fifteen hours, so 
that one hundred and seventy grains were administered. The child, 
which had previously been restless, fell into quite a natural sleep. The 
calomel was discontinued, and a mixture of potassium chlorate and am- 
monium chloride given in its place. On the fifth day convalescence was 
fully established, without any unfavorable symptoms. 

Case. — The third patieut, a girl of four years, had been sick twenty- 
four hours, with " high temperature, painful croupy cough, labored respi- 
ration, dry skin, flushed face, and some diphtheritic " exudation. Twenty 
grains of calomel were administered and followed by hourly ten grain 
doses, till twelve doses were given. No other remedy was employed, and 
in three or four days the patient recovered. 

These appear to have been genuine cases, and that they recovered 
tends to confirm the belief that calomel does exert a beneficial action on 
pseudo-membranous inflammations, either diminishing the exudation, or 
promoting the liquefaction and detachment of the pseudo-membrane. 

A mode of treatment commonly accepted and practised by the profes- 
sion through a long series of years usually does some good, in at least a 
certain proportion of cases, even if it be abused, else it w r ould not have 
been likely to gain general acceptance. We know how quickly calomel 
cures the mucous patches of syphilis, even when they are of large size. 
These are produced by inflammatory changes in the tegumentary system, 
and they consist largely of epithelial or epidermic cells. They, there- 
fore, contain elements similar to the pseudo-membrane in croup, but 
without the fibrin. We know also how readily fibrinous opacities on 
the cornea yield to calomel dusted on them. We may admit that calomel 
probably exerts a salutary action either on the exudative process or the 
pseudo-membrane, without being able to state precisely how it acts. 
Bouchut says of calomel in his article on croup : " This medicine pro- 
motes the expectoration and the rejection of the false membrane." 
Trousseau believed that the beneficial effects of the mercurial prepara- 
tions were due mainly to their local action. He states that "wherever 
they can be applied locally" they "modify most powerfully the diph- 
theritic inflammation." He dusted the inflamed surface, if accessible, 
with calomel, or with a powder of the red precipitate, one part to twelve 
of pulverized sugar. The use of the mercurial collar for the neck in 

1 Med. Kecord, July 12, 1884. 



584 MEMBRANOUS CROUP. 

the treatment of croup, employed and recommended by Bretonneau, is 
familiar to those who have read his memoirs. Professor Jacobi also, 
who has probably given more attention to diphtheria than any other 
physician in America, apparently believes that mercury used locally is 
beneficial in croup, for he has recently recommended inunction with the 
oleate of mercury upon the neck, whenever the bichloride of mercury 
administered internally disagrees. It has seemed to me that one or two 
large doses of calomel administered in the commencement of croup, when 
there is no decided cachexia, do exert a beneficial action on the course 
of the disease, as in the following : 

Case. — R., male, aged three years, began to be croupy, but without 
any marked impairment of the voice, on November 7, 1884. The mother 
states that he has had sore throat nearly one week, but without medical 
attendance. He began to be croupy on November 7th, and his respira- 
tion gradually became more noisy and difficult till the evening of the 8th, 
when I was asked to see him. 

His temperature was 99°. The dyspnoea was such that the post-clavi- 
cular, suprasternal, and inframammary regions were depressed on inspi- 
ration, and his breathing was noisy, but the voice had nearly the usual 
clearness. The fauces, though red, were not notably swollen, and a pseudo- 
membranous patch of the size of the nail of the little finger lay over the 
right tonsil. The diagnosis was, therefore made of mild diphtheria, but 
with dangerous laryngeal stenosis, probably from the presence of a pseudo- 
membrane : general condition of the child good. Six grains of calomel 
were placed on the tongue, and inhalation was ordered by the steam 
atomizer of the following : 

J£. — Liquor potassse ....... gj. 

Aquse calcis ........ Oj. — Misce. 

The record of November 10 states : Resp. 38 per minute, still noisy 
but no increase of dyspnoea ; pulse 126; temperature in groin 99£° ; slight 
discharge from nostrils ; uses the inhalation almost constantly. From 
this date the pseudo-membrane and redness of the fauces gradually disap- 
peared, and two days later the patient was out of danger. 

The results of the treatment of diphtheria and of the inflammations 
which accompany this disease are liable to produce an erroneous opinion 
in regard to the value of therapeutic agents, since cases differ so greatly 
in type or severity. But the experience of many physicians justifies 
the belief that mercury and especially calomel, employed within certain 
limits in the commencement of a pseudo-membranous inflammation, does 
exert some controlling action on this disease. That it did much harm 
formerly when physicians prescribed it as freely as we now employ 
potassium chlorate to the extent in many instances of increasing the 
cachexia, and causing mercurialism, should not deter from its judicious 
use. In the ordinary form of diphtheria I would not advise the use of 
calomel, or would limit its employment to one or two doses of six to ten 
grains in the commencement of the disease in robust cases. But in 
croup, since the danger is not from the cachexia or blood-poisoning so 
much as from the laryngeal stenosis which usually develops rapidly, 
that medicine is indicated, and should be prescribed, which most strongly 



INTERNAL DISINFECTANTS OR GERMICIDES. 585 

retards the exudative process, and aids in liquefying and removing the 
pseudo-membrane ; provided that it produce no deleterious effect which 
renders its use inadmissible. Hence it is proper to prescribe calomel in 
larger doses and for a longer time in the treatment of croup, than in 
other forms of membranous inflammation, if it fulfil the indication as it 
seems to in a measure. In my own practice, however, calomel is not 
prescribed after the first or second day, since I prefer the use of other 
remedial measures, which are efficient, and are less likely to produce in- 
jurious effects. 

Emetics. — These have been largely used in all forms of croup, and 
in catarrhal or spasmodic croup they usually produce marked relief. 
Formerly emetics were much employed in the treatment of membranous 
croup, but now that diphtheria has spread throughout the country, and 
most cases of this form of croup occur in patients suffering from diph- 
theritic blood-poisoning, depressing emetics as ipecacuanha and antimony 
have fallen into disuse since they were found to be badly tolerated. In 
my practice a child of ten years with severe diphtheria and with com- 
mencing croupy symptoms, sank rapidly and died between two of my 
visits, from exhaustion produced by a single large dose of ipecacuanha 
administered by anxious parents without my advice. 

But an emetic gives partial relief to the dyspnoea in certain cases, 
since it assists in expelling the muco-pus which blocks up the tubes 
below the pseudo-membranes, and sometimes portions of pseudo-mem- 
brane which are easily detached. If an emetic be employed, one should 
be selected which acts promptly with little depression, and as a rule it 
should, I think, only be used at the commencement of croup. If after 
the initial period there be that degree of dyspnoea which suggests its 
use, tracheotomy is preferable as more likely to give relief, and save the 
patient. Of the emetics which are admissible in the commencement of 
croup, sulphate of copper is one of the best. Several years since in one 
case, in which there were at my first visit dyspnoea, croupy cough, and 
a pseudo-membrane over each tonsil, and in which I had made an un- 
favorable prognosis, the parents, observing the good effects of two grains 
of sulphate of copper, repeated the dose every two to four hours till the 
following day, and the patient recovered. Such a result however I 
regard as exceptional. Probably in ordinary cases the best emetic is 
the yellow sulphate of mercury or turpeth mineral in a powder of two 
or three grains. The use of this emetic in croup was prominently 
brought to the notice of the profession by Prof. Fordyce Barker, who 
administered this agent immediately after being summoned to a case, 
and he alleges with remarkable benefit to his patients. It has, however, 
been recently stated on apparently good authority that turpeth mineral 
when it enters the stomach, although it causes vomiting, is not itself 
ejected unless in small quantity, so that a considerable share of its action 
may be through its absorption and like that of calomel. 

Internal Disinfectants or Germicides. — The theory which 
happens to prevail regarding the nature of a disease necessarily influ- 
ences the treatment. It is now commonly believed that diphtheria is 
produced by bacteria, and therefore the use of agents which are de- 
structive to microorganisms is at once suggested as the proper treat- 



586 MEMBRANOUS CROUP. 

ment for diphtheria, and for the inflammations which the specific prin- 
ciple of diphtheria gives rise to. Hence sulphite of sodium, sulpho- 
carbolate of sodium, the phenic acid of Declat, and chlorine preparations 
have been administered internally in the treatment of diphtheria, but 
whether they produce a better result than iron and potassium chlorate 
is doubtful. 

But attention is now widely drawn to the bichloride of mercury, which 
by common consent is more destructive to microorganisms, when em- 
ployed locally, than any other agent that can be safely used. Physi- 
cians in search for a remedy that would destroy micrococci in the system 
and thus remove the cause of diphtheria were naturally led to make trial 
of this agent in the hope that an antidote or specific had been found. 
If the bichloride can be safely administered in doses sufficiently large, 
there is every reason to suppose that it will destroy the microbe, in the 
interior of the body as well as upon its surface. If clinical experience 
show that it can be used in such doses without poisonous effect, it de- 
serves recognition as the specific for diphtheria. If, without injury to 
the patient, it act promptly enough to kill the microbe before serious 
organic changes have occurred in the organs, as granulo-fatty degenera- 
tion of the muscular fibres of the heart, or nephritis, it would save many 
lives and become as important a remedy for diphtheria as quinine is for 
diseases produced by marsh miasm. But unfortunately we have to deal 
with an agent long recognized as a deadly poison, and it is a problem 
yet to be solved whether it would not destroy the patient if employed 
in doses sufficient to destroy the micrococci. A strong argument in 
favor of this use of the bichloride was presented to the profession by 
Dr. Thallon, 1 of Brooklyn. His argument was substantially as follows: 

It has been shown that the bichloride of mercury destroys the bacteria 
in a liquid having 20,000 times its weight. Now, if 20,000 grains of 
blood are disinfected by one grain of the bichloride, 7000 or one pound 
are disinfected by one-third of a grain. Prof. Flint, Jr., states that, 
although the proportionate quantity of blood in the system varies in dif- 
ferent individuals, it may be assumed that on the average it is in the 
proportion of one to eight of the entire weight of the body. Therefore 
one grain of the bichloride would destroy the microbes, and disinfect 
the blood, in a child weighing twenty-four pounds, two grains in one 
weighing forty-eight pounds. But if the bichloride can be safely ad- 
ministered to a child in such doses that its system contains one or two 
grains, still it must be remembered that in diphtheritic systemic poison- 
ing micrococci occur in the lymphatics and the tissues, and therefore a 
considerably larger quantity of the bichloride is necessary to produce 
complete disinfection than the quantity which is required to disinfect the 
blood. 

But whether the bichloride administered internally, is a safe, efficient, 
and proper remedy for diphtheria must be determined by experience. 
If it be shown to be such by clinical observations, it should of course be 
administered in all cases, whatever be the seat of the inflammation. It 
should be administered in the croup of diphtheria, since if we remove the 
cause, the inflammation will abate or can be more successfully treated. 

1 N". Y. Jour, of Medicine, April, 1884. 



INTERNAL DISINFECTANTS OR GERMICIDES. 587 

A considerable number of observations have been made in the last 
year showing that adults badly tolerate large doses of the bichloride. 
Thus one-twentieth of a grain administered hourly to an adult with 
phthisis till seven or eight doses were given each day produced bloody 
diarrhoea at the close of the third day, when about one grain had been 
taken. The same result followed in another adult when one-twentieth 
of a grain had been administered every second hour in the daytime only, 
for four days. In a third patient one-twentieth of a grain given hourly 
in the daytime for five days caused profuse salivation and pain in the 
gums like that from calomel. A fourth adult patient took one-thirty- 
second of a grain hourly for eleven hours, and then one-tAventy-sixth of 
a grain for seven hours, when griping pain in the abdomen occurred, 
and liquid stools. (Dr. A. H. Smith.) One adult case only is related 
in the experiments of Dr. Smith, in which no ill-effects followed the 
administration of one-twentieth of a grain doses of the bichloride though 
administered hourly in the daytime for eight days. Cases might be 
mentioned in the practice of other physicians, showing that the bichlo- 
ride is a dangerous remedy if given in germicide doses in the treatment 
of adults. In one instance in my practice bloody diarrhoea occurred on 
the fourth day from the uterine douche used three or four times daily, 
and fatal cases have been announced in the journals from the douche. 

But children seem to tolerate the bichloride better than adults, as 
they do arsenic. It has been largely used during the last year in New 
York as a remedy for diphtheria, and especially for diphtheritic croup, 
and physicians of experience state that more patients have recovered 
from croup under treatment by the bichloride than from any other 
medication which they had previously employed. (Jacobi.) The fol- 
lowing brief statement of the effects of the bichloride treatment in diph- 
theria and croup in a few cases in the practice of Drs. Thallon, Armor, 
Skene, Jacobi, and myself will aid to an understanding of the therapeutic 
value of this agent in pseudo-membranous inflammations. 

Case. — A child of 6} years, having diphtheria after scarlet fever, took 
gr. -£ s hourly, most of the time for one week, and subsequently the same 
dose hourly in the daytime, and two or three times at night, with no un- 
favorable symptoms ; but the urine was increased to 70 ounces. A child 
of 4 years, having croup, complicating diphtheria, and with urgent symp- 
toms, took gr. ^o of the bichloride every hour and a half to three hours. 
In five and a half days she took more than two grains, and in one day 
more than half a grain. Portions of the pseudo-membrane were expec- 
torated, and the patient recovered. There were no unfavorable symptoms 
from the bichloride. 

Of five children who recovered from the ordinary form of diphtheria 
reported by different observers, one, aged 9 years, took gr. -fo every one 
and a half hours, and in one day nearly half a grain, till the fifth day, 
when a little over two grains had been taken. The second child, also 
aged 9 years, took nearly one-half grain of the bichloride in the first 
twenty-four hours, and in two days, three-quarters of a grain. The 
third patient, aged 4J years, took gr. ^ of the bichloride every two 
hours on the first day, and afterwards at longer intervals. In the fourth 



538 MEMBRANOUS CROUP. 

case, a child of 7J years, gr. -fe was given every two hours, for how 
long is not stated, but the membrane became less on the second day. 
The fifth patient, aged 2 years 5 months, had a hoarse whispering voice 
and noisy (guttural) respiration ; temperature 105°. The pseudo-mem- 
brane appeared over the tonsil in considerable quantity at the close of 
the second day. The bichloride, gr. ^ was given every second hour 
alternately with six minims of the tincture of the chloride of iron. Al- 
kaline inhalations were constantly used, and one teaspoonful of brandy 
given every two hours. The bichloride was administered three davs 
with no appreciable ill-effect, and with gradual improvement of the 
patient. 

Although during the last few months the bichloride has been largely 
used as a remedy for diphtheria and pseudo-membranous croup, in doses 
like those employed in the above cases, but few instances have been 
published in which it seemed to disagree. It has, however, in some 
patients caused diarrhoea, and apparently colicky pains, as in adults, so 
that it was deemed advisable to discontinue its further use. According 
to my observation it does not save life, or materially mitigate the inten- 
sity 'of the disease, or the inflammation, if profound blood-poisoning, or 
grave complications, as nephritis, have occurred when its employment 
is commenced. 

The following cases, among others which have come under my obser- 
vation, show that the bichloride if administered in grave cases at a late 
stage is powerless to save life : A child of 3 J years, with malignant diph- 
theria, took at first the ordinary remedies, such as iron and potassium 
chlorate, and when the urine had become heavily albuminous, and the 
fauces much swollen and covered with a dense and foul pseudo-membrane, 
the bichloride was prescribed in hourly doses of gr. -£%. Two days later 
death occurred, apparently from the blood-poisoning. Another patient 
of the same age, and nearly the same history, lived four days under the 
bichloride treatment. Perhaps better results might have occurred from 
its earlier use. 

Clinical observations will soon determine the actual value of the 
bichloride in the treatment of diphtheria and diphtheritic inflamma- 
tions ; and if it be a safe and useful remedy, whether its beneficial 
effects are due to its germicide action, or to the same therapeutic 
effects as those obtained from other mercurial agents. It may be con- 
veniently prescribed in the following formulae recommended by Pepper 
and Thallon : 

R . — Hydrarg. bichlor. ..... gr. ss. 

Tine, ferri chloridi .... fg"j- 

Glycerinse . . . . . . fjss. 

Aquae . . . . . . . q. s. ad f^iij. — Misce. 

One teaspoonful every hour to two hours. 

R . — Hydrarg. bichlor. ..... gr. ss. 

Elix. bismuthi, 

Vini pepsin i aa ^ iss. — Misce. 

One teaspoonful every hour to two hours. 

It does not seem necessary or prudent in ordinary cases to continue 
the use of the bichloride more than three or four days in large and fre- 
quent doses. 



SURGICAL TREATMENT. 589 

Since membranous croup in localities where diphtheria prevails is in 
most instances a local manifestation of this disease, the same sustaining 
general treatment is required which is proper in ordinary cases of 
diphtheria. The tincture of the chloride of iron, administered every 
second hour in liberal doses, potassium chlorate, quinine, brandy or 
other form of alcohol in large and frequent doses, long used in diph- 
theria as tonics and blood restorers, are indicated. Medicines of this 
kind may be given between those which are designed to correct the 
exudative process, and aid in removing the laryngeal obstruction, and 
which have been described above. The diet should be nutritious and 
easily digested, consisting largely of milk and the meat teas. For 
those with poor appetite and feeble digestion, peptonized milk, and the 
peptonized meat juices may often be advantageously prescribed. 

Surgical Treatment. — Although the best possible treatment by 
inhalations and internal medication be early employed and without 
intermission, yet it is the common experience in all countries that such 
treatment is in a large proportion of cases inadequate, and that many 
perish from suifocation unless relieved by surgical interference. We 
have stated above, that if croup occur at the commencement of diph- 
theria when the exudative process is active, and the pseudo-membranes 
form rapidly and abundantly, death is the common result, if medicinal 
treatment only be employed. But if the inflammation be less intense 
or subacute, as in the second week of diphtheria, so that there is more 
time for the action of medicines and inhalations, and if, as is sometimes 
the case, the stenosis appear to be at a stand-still, without any marked 
suffering from want of air, resort to surgical measures may be judiciously 
postponed. 

The indications for surgical interference are a gradual increase of the 
stenosis and consequent dyspnoea, notwithstanding the constant and 
judicious use of remedial agents, and a manifest suffering from want of 
air as shown by restlessness of the child, and the expression of suffering 
in his features, with or without lividity of the surface. We, adults, may 
have some faint conception of the suffering, which children with acute 
laryngeal stenosis undergo, when we have severe nasal catarrh and 
attempt to breathe with the mouth closed, and the paramount duty of 
the physician to relieve suffering should prompt to a resort to other 
measures when medicines prove inadequate, even if we leave out of 
account the important object of saving life. \Yhen therefore membra- 
nous croup is found to be progressive after having been observed and 
properly treated from six to twenty-four hours, and the child begins to 
suffer from want of air, the propriety of surgical interference should be 
considered. 

Tubage. — In 1858, Bouchut 1 published a paper on a new method of 
treating croup by tubage of the larynx. He employed a straight cylin- 
drical tube nearly an inch long. The tube was introduced by means 
of a male catheter open at its two ends. Tubage excited some attention 
and discussion at the time in the Parisian capital, and M. Gros related 
a case of its successful employment. It was found in experiments on 

1 Aloniteur des Hopit. 



590 MEMBRANOUS CROUP. 

animals that the tube caused ulcerations, and as it did not produce the 
uniform relief which follows tracheotomy, and was discountenanced by 
Trousseau, Barthez, and others, it fell into disuse, and was abandoned 
as a substitute for tracheotomy even by those who at first warmly advo- 
cated it. Recently Dr. 0. Dwyer, of the New York Foundling Asy- 
lum, has devised a tube of about the same length, but differing from 
that of Bouchut, in having a greater antero-posterior than lateral 
diameter, and therefore conforming to the shape of the laryngeal aper- 
ture. The left index finger, guarded by a broad metallic ring, is car- 
ried far back in the mouth of the patient so as to depress the root of 
the tongue and raise and fix the epiglottis, and the tube is introduced 
by a curved handle, attached to its inner surface ; the handle is de- 
tached by a spring. The tube can be readily removed by attaching the 
handle to the same fastening on its inner surface. Tubing as thus em- 
ployed usually relieves laryngeal stenosis, and I am not aware that the 
instrument of Dr. 0. Dwyer, although employed in a considerable num- 
ber of instances, has produced ulceration or other injury of the larynx. 

Case. — On May 21, 1884, during my term of service in the New York 

Foundling Asylum, Florence- , 3 J years, was admitted at the time 

of my visit, suffering from extreme dyspnoea. The symptoms of acute 
laryngeal stenosis were so pronounced, such as great depression at the 
summit and base of the chest on inspiration, restlessness, and the appear- 
ance of anguish in the features from want of air, that the child apparently 
could not live more than two or three hours without relief. The fauces 
were somewhat hypersemic, but without pseudo-membrane. The tube was 
applied by Dr. O. Dwyer, with immediate relief of the dyspnoea, and the 
expectoration of a large quantity of muco-pus. Liquid food was readily 
swallowed when the tube was present, but occasionally some of it entered 
the air-passages, provoking a cough. Three hours after the insertion of 
the tube the axillary temperature was 102°. 22d. Breathing still easy; 
axillary temp. 103° ; pulse 130. 23d. The tube has given complete relief; 
a small pseudo-membrane exists on each side between the uvula and ton- 
sils. 28th. The tube was expectorated to-day, and as the respiration 
remained normal without the tube, it was not replaced. 30th. Temp. 
99f° ; pulse 136, at times as low as 80; has a loose cough. When the 
tube was worn and immediately afterwards she expressed her wants in a 
feeble whisper, which could be understood even when the vocal cords 
were covered by the tube. The voice gradually returned after the expul- 
sion of the tube, and no further treatment was required. The suffering 
of the patient was quickly relieved, and her life apparently saved by 
tubage. 

The tube when in situ does not produce a cough, or apparently any 
unpleasant sensation in the larynx. Tubage would in my opinion 
come into general use as a substitute for tracheotomy, were it not for 
the fact that the pseudo-membrane in so large a proportion of cases 
extends beyond the larynx, and the tube fails to relieve tracheal and 
bronchial obstruction. Since tracheotomy gives equally prompt relief 
to the dyspnoea, and in a larger number of cases, and enables us to 
remove the obstruction from the trachea, and to a certain extent from 
the bronchial tubes through the artificial opening, the almost universal 



TRACHEOTOMY. 591 

opinion in both continents that it is preferable to tubage or any other 
surgical measure, has a valid foundation. Usually it is best not to defer 
tracheotomy, in order to make the uncertain trial of tubage, when the 
symptoms are so urgent that surgical measures are required. 

Tracheotomy. — Since diphtheria has spread so widely, tracheotomy 
has become one of the most important operations in surgery. Properly 
performed, and at the proper time with judicious after-treatment, it 
rescues many children from a most painful death. The details of this 
operation are given in surgical treatises, but some general remarks re- 
lating to it will not be inappropriate here. 

Sanne says that the operator should have three assistants, at least 
one of them a physician. One should administer chloroform, one use 
the sponge, and the third, a physician, should be ready to assist in 
handing instruments, ligating vessels, etc. The operation is simple and 
devoid of danger, or difficult and dangerous, according to circumstances. 
The younger the child, the greater the danger, other things being equal. 
The greatest difficulty and risk attend tracheotomy in fleshy infants with 
thick and short necks, and in patients who have extreme dyspnoea, and 
are nearly moribund, so that the operator is impelled to hurry in the 
operation through fear that death will occur before the trachea is opened. 
The operator should have time for slow and cautious dissection, that he 
may avoid wounding vessels and other important parts. 

The patient to be operated on should be placed on his back on a table 
covered by a blanket, and a bottle or block about four inches in diameter 
should be placed under his neck, so that the head is thrown back at an 
angle of forty-five degrees, and the anterior surface of the neck rendered 
prominent. Chloroform is then administered. An incision should be 
made through the skin in the median line one and a half to two inches 
in length, according to the age, and extending to within half an inch of 
the sternum. Through the connective tissue to the trachea the dissec- 
tion should be slowly and cautiously made with the point of the knife, 
the scissors, and the blunt hooks which are used to tear the connective 
tissue and draw aside vessels. The tip of the finger occasionally pressed 
upon the trachea aids in determining its location, and serves to guide 
the dissection, which should always be in the median line. Little cut- 
ting is required after the skin has been divided, but when fibres of con- 
nective tissue resist the blunt hooks, they should be cut either by the 
point of the knife or the scissors. A grooved director is also useful in 
the dissection, since by it the operator is enabled to raise and tear re- 
sisting fibres, or detach them from parts underneath, so that they can 
be more readily divided. 

Some surgeons prefer the high, others the low operation In the 
high operation the trachea is found nearer the surface, and the vessels 
in the way are less numerous than in the low operation. In the opera- 
tion, however, the trachea is usually opened at that point, whether high 
or low, which is most readily reached and laid bare. When this tube 
is exposed a longitudinal incision is made through its anterior wall suffi- 
ciently long to allow the canula to be inserted. It facilitates opening 
the trachea if it be held by a tenaculum constructed for the purpose with 
the hook bent so as to be at right angles with the handle. The length 



592 MEMBRANOUS CROUP. 

of the incision through the trachea should be about five-eighths of an 
inch. The canula should not be immediately introduced, but the patient 
should be made to cough by inserting a pigeon's quill down the trachea 
into the bronchial tubes. Blood, muco-pus, and shreds of fibrin, if any 
be present, are expelled through the opening by the cough which the 
quill produces. The canula is now introduced with or without the aid 
of the tracheal dilator. The one which is in common use is that devised 
by Trousseau, with some subsequent improvements. It consists of two 
concentric cylinders, the external fenestrated, and the disk or plate 
which supports the tubes is movable upon them. 

The result depends to a great extent on the subsequent treatment. 
The common result is immediate relief to the dyspnoea, but unfortu- 
nately in a large proportion of cases the temperature rises about the 
third day after the operation, and pseudo-membranes begin to form in 
the bronchial tubes, and in some instances broncho-pneumonia results. 
Surgeons have endeavored to prevent the formation of membranes in 
the bronchial tubes after tracheotomy by allowing lime-water to trickle 
through the aperture into the tubes. Perhaps some other solvent of 
pseudo-membranes, as bicarbonate of soda or trypsine, might be prefer- 
able for this purpose. No surgical operation more imperatively requires 
intelligent and attentive after-nursing than tracheotomy, since the canula 
needs to be frequently removed and cleaned whenever obstructed by muco- 
pus. The febrile movement alluded to above as indicating the extension 
of the inflammation downwards in the tubes may be in a measure relieved 
by the application around the chest of one or two thicknesses of muslin 
wrung out of cool water and covered by oil silk. No certain time can be 
foretold for the removal of the canula if the patient live. If on withdraw- 
ing the inner tube and applying the finger over the end of the remaining 
canula, the patient breathe easily through fenestra, the laryngeal stenosis 
has probably so far abated that the tube can be safely removed. 

The following is a description of the instruments in the tracheotomy 
case of one of the most skilful operators in New York City, Dr. Fred. 
Lange. All of them have small handles like those of dental instruments. 

1. a. A scalpel, with cutting edge convex, the blade 1J inches in 
length, and its greatest width | inch. This scalpel is employed in 
dividing the skin and in the subsequent dissection, b. A scalpel of 
same length, but with narrower blade and straight cutting edge, used 
for opening the trachea. 

2. Two blunt hooks, with the hook straight, J inch in length, extend- 
ing at a right angle from the handle, having a diameter scarcely larger 
than a carpet needle. The end of the hook is slightly bulbous. A 
considerable part of the dissection is performed by the blunt hooks 
which are used in tearing the connective tissue. 

3. Three artery clamps, by which bleeding vessels or oozing surfaces 
are seized, and the instruments with their points attached to the bleed- 
ing surfaces are dropped upon the sides of the neck. They thus aid in 
drawing open the wound. 

4. Tenacula. Two with hooks in line with the handle ; two others 
with hooks at right angle to the handle ; the diameter of the curves in 



BRONCHITIS. 593 

the hooks J inch. Those with hooks at right angles are employed for 
transfixing and holding the trachea when it is to be opened. 

5. Two grooved directors, one with the end smaller and more pointed 
than that of the other. 

6. A common artery forceps, also forceps with fine teeth. 

7. The spring hook of the oculist, employed by him in separating 
the eyelids ; it holds apart the edges of the wound. 

8. "The tracheotomy tube consisting of two concentric cylinders, de- 
scribed above. 

9. Pigeon's quills ; these are important for removing muco-pus and 
fibrinous shreds from the trachea and bronchial tubes. An instance 
has come to my knowledge in which the physician who assumed charge 
of the case after the operation attempted to use for this purpose a small 
piece of sponge held by forceps ; he unfortunately loosened his hold, 
and the sponge drawn in with the breath produced immediate death by 
suffocation. This would not have happened with the pigeon's quill. 

When the operation is completed and the canula introduced, iodoform 
should be dusted upon the wound, and two thicknesses of linen soaked 
with the solution of bichloride of mercury, one part to two thousand, 
notched so as to surround the canula and pass under its plates, should 
be applied over the wound, and every hour moistened with the bichloride 
solution. With such treatment the wound preserves a healthy appear- 
anee and heals readily. 



CHAPTEE IY. 

BRONCHITIS. 

Inflammation of the bronchial tubes, or bronchitis, is probably the 
most frequent disease of early life. It is usually associated with more 
or less inflammation of the mucous membrane of the nostrils, larynx, 
and trachea. We designate the disease coryza, laryngitis, or bronchitis, 
according as one or the other inflammation predominates. Sometimes 
bronchitis occurs with but slight inflammation elsewhere, and often the 
coryza and laryngitis abate while the bronchitis is still active. 

Bronchitis occurs both as a primary and secondary disease. The 
secondary form is common in connection with measles, hooping-cough, 
pneumonia, and pulmonary phthisis, and it is not uncommon in remit- 
tent and continued fevers. Bronchitis is acute, subacute, or chronic, 
and according to its extent it is mild or severe. If the smallest bron- 
chial tubes are involved, the inflammation is designated capillary bron- 
chitis, a term not well chosen, but which is conveniently employed 
in a description of the malady. Bronchitis is commonly bilateral, 
affecting the tubes on the two sides with about equal intensity. When 

38 



594 BRONCHITIS. 

due to tubercles, or to pneumonia, it is often unilateral, being confined 
to those tubes or nearly to those which are surrounded by tubercular 
or inflammatory product. 

Causes. — The causes of secondary bronchitis are obviously the dis- 
eases in connection with which it occurs. The cause of primary bron- 
chitis is the same as that of simple acute laryngitis or coryza, namely, 
sudden change of temperature from warm to cold, exposure to currents 
of air, the practice of sending children without sufficient clothing from 
heated rooms into the open air, the throwing off of bedclothes at night, 
etc. Dentition is also an occasional cause, since some children have 
attacks. which coincide with the eruption of the teeth. The cough of 
dentition is usually purely a nervous affection ; but in other instances it 
is accompanied by more or less mucous secretion, and is evidently de- 
pendent on a mild catarrh. 

Anatomical Characters. — In the most common form of bronchitis 
the larger bronchial tubes only are affected. They are the seat of the 
inflammation in most of those cases which are designated "colds" by 
families, and which are often treated without the aid of the physician. 
The lining membrane of the bronchial tubes presents the ordinary ana- 
tomical characters of mucous inflammations. It is reddened uniformly 
or in patches intensely, or in that milder degree known as arborescence, 
according to the severity of the inflammation. 

The secretion of the muciparous follicles is at first arrested, and the 
surface of the membrane is dry. In the course of a day or two the 
secretory function is reestablished, and the surface is covered with thin 
and transparent mucus. A day or two later, the secretion becomes 
thicker, consisting of mucus and pus. Mixed with these substances are 
epithelial cells, which are exfoliated in abundance from the inflamed 
surface. At the same time the mucous membrane becomes thickened 
and more or less softened. If the inflammation be severe, the vessels 
of the submucous connective tissue are also injected. 

Usually, in about a week in the young child, in from one to two 
weeks in older children, the inflammation begins to abate. Gradually 
the inflamed membrane returns to its normal consistence, thickness, and 
vascularity, and with this return to the healthy state the muco-purulent 
secretion abates. 

In this, which is the simplest and most common form of bronchitis, 
there is no ulceration, and rarely any pseudo-membranous formation, if 
the disease be idiopathic. Pseudo-membranous bronchitis is not unusual 
as an accompaniment of pseudo-membranous laryngo-tracheitis. 

Were bronchitis limited to the larger bronchial tubes, it would indeed 
be a simple affection, but unfortunately it has a tendency to extend 
downward. Commencing in the larger, it gradually invades. the smaller 
tubes in a similar manner to the extension of erysipelas upon the skin. 
More rarely the inflammation commences simultaneously in the larger 
and smaller tubes. Now the gravity of bronchitis is proportionate to 
the degree of its extension downward. It may stop at any point in its 
progress, but if it reach the smaller tubes it is one of the most serious 
affections of early life. 

The mucous membrane of the minute tubes, those next to the air- 



ANATOMICAL CHARACTERS. 595 

cells, is delicate, with but little submucous connective tissue, and it fre- 
quently, at post-mortem examinations, does not present to the eye those 
distinct inflammatory changes which are observed in tubes of large 
diameter. It is sometimes not notably thickened, nor its vascularity 
much increased, even when there is reason to believe from the symptoms 
that it was the seat of active phlegmasia. As we pass from these minute 
tubes to those of larger calibre, the inflammatory lesions become more dis- 
tinct. The inflammation produces minute and abundant points of redness 
and the membrane is evidently thickened; often it is rough or granular. 

The minute bronchial tubes are very small, especially under the age 
of three years, and since in capillary bronchitis a large proportion of 
them are inflamed, the source of the danger is apparent. It is with 
difficulty that the patient with capillary bronchitis can, by the effort of 
coughing, free the tubes from the secretions which are constantly col- 
lecting in them. In weakly children, under the age of two years, ex- 
pectoration is most difficult, and hence the great and increasing dyspnoea 
from which such patients suffer. 

In severe and unfavorable cases of bronchitis, which are chiefly those 
in which the small as well as large tubes are inflamed, the following ana- 
tomical changes commonly occur : The muco-purulent secretion, which 
is tenacious, collects more rapidly in the smaller tubes than it is expecto- 
rated by the child, whose strength begins to be exhausted. The accu- 
mulation of the secretion is chiefly in the tubes which lie in the posterior 
and inferior portions of the lung. As the obstruction from the muco- 
pus increases in these tubes, less and less air passes through them into 
the alveoli with which they communicate, while the quantity of air which 
passes through the unobstructed tubes into the anterior and superior 
portions of the lung is proportionately increased. The effect, as regards 
the state of the lung, is obvious. In cases having a fatal issue, and in 
which we are therefore able to inspect the lesions, we find that the lower 
and inferior portions of the organ, from which air was to a greater or 
less extent excluded, have a diminished crepitation, that they lie a little 
below the general level, or that certain' lobules do, and that they present 
a congested appearance, for while they contain too little air they have 
an excess of blood. We shall also find that the upper and anterior parts 
of the organ, perhaps the entire upper lobe, contain more than the 
normal quantity of air, so as to rise above the general level. There is 
distention of the alveoli in these parts, so that they are probably visible 
to the naked eye, and may appear to be emphysematous, but this is a 
state distinct from emphysema. It is merely an inflation of the alveoli 
to nearly their full capacity. 

Here and there in the portion of lung in which the inflation has been 
incomplete, lobules may be observed which are entirely collapsed, having 
a dusky red color and no crepitation ; while in other parts, if the bron- 
chitis have continued some days, there may be nodules of pneumonia. 
The incised surface of those portions of the lung to which the access of 
air has been prevented, whether they are collapsed fully, or partially or 
not, has a reddish color from congestion, and is moist from serum and 
blood. On compressing the lung, the muco-purulent secretion appears 
upon the surface in points, having escaped from the divided ends of the 



596 BRONCHITIS. 

tubes. For other facts relating to atelectasis, the reader is referred to 
the chapter in which this malady is described. 

Exceptionally even when not accompanied by laryngeal croup, fibrin- 
ous exudation occurs in the bronchial tubes, forming a delicate film, 
here and there, and readily detached from the surface underneath, while 
in rare instances it occurs as a firm and continuous membrane, forming 
a mould of the tubes, increasing greatly the dyspnoea, and constituting a 
true bronchial croup. If the patient with severe bronchitis survive, the 
inflammation of the mucous membrane soon begins to abate. The tubes 
which have been the seat of the disease, and the alveoli which have been 
secondarily involved, may return to their normal state almost immedi- 
ately; but in other instances such anatomical changes occur in them, 
even when there is no pneumonia, nor atelectasis, that full restoration 
to their normal state is necessarily somewhat slow. When the function 
of a lobule ceases, as it does when the tube leading to it is obstructed, 
not only hyperemia occurs with or without collapse, as already stated, 
but its cells and nuclei, and perhaps other parts, begin to undergo fatty 
degeneration. These elements become granular, somewhat enlarged 
and opaque, and here and there mixed with them are other large cells 
filled with oil-globules. These are the compound granular cells of path- 
ologists, and, occurring in this situation, are produced by metamorphoses 
of the epithelial cells. They are epithelial cells which have progressed 
more rapidly than others in fatty degeneration, having reached that 
stage of it which immediately precedes liquefaction. We often with the 
microscope observe not only these corpuscles, but their fragments as 
they are dissolving. 

Minute abscesses, usually directly under the pleura, have occasionally 
been observed at the autopsies of those who have recently had general 
bronchitis, and pathologists are not agreed as to the mode in which they 
are produced. Some of them, if not all, are evidently connected with 
the minute bronchial tubes, and the quantity of pus contained in each 
is not usually more than one or two drops. The most reasonable view 
of their causation is that they are produced in the terminal tubes where 
the mucus and pus collect. The pus acts as an irritant and causes in- 
flammation, and the inflammation increases the quantity of pus. The 
walls of the tube which is now the seat of an abscess are destroyed by 
ulceration, and probably, also, some of the contiguous air-cells. The 
little cavity is soon surrounded by a delicate membrane, the same in 
character, though less thick and firm, as that which constitutes the walls 
of larger abscesses. The pus presents the usual appearance of this 
liquid, or it may be tinged by the presence of blood-cells, or again it 
may be thick from partial absorption of the liquor puris so as to resemble 
softened tubercle. 

The abscess is ordinarily located in the centre of a collapsed lobule. 
In certain cases it approaches the surface of the lungs, so as to produce 
circumscribed pleurisy, with adhesion of the costal and visceral pleura. 
At the autopsy of such a case, on separating the adhesions and attempt- 
ing insufflation, the air passes through the aperture, so that the lung 
on that side cannot be inflated unless the aperture be closed. Occa- 



SYMPTOMS. 597 

sionally pneumothorax results from opening of the abscess into the 
pleural cavity. 

In severe protracted bronchitis dilatation of certain of the bronchial 
tubes sometimes results. The alveoli in the upper lobes may also be 
distended beyond their physiological capacity, so as to produce emphy- 
sema, but, as we have stated above, their maximum distention within 
physiological limits must not be mistaken for emphysema. Emphysema 
in the upper lobes is common in feeble young children, with relaxed and 
weakened tissues, occurring even without any severe disease of the re- 
spiratory organs. It may be vesicular or interstitial. If it be inter- 
stitial the sacs of air often attain considerable size, lying as wedges 
between the alveoli, or like little bladders upon the surface of the lung. 
It is not difficult to understand how emphysema occurs in severe bron- 
chitis, since the air partly arrested in the tubes leading to the lower 
lobes enters the upper lobes in increased volume and force. 

Symptoms. — It is evident, from the description which has been given 
of the anatomical characters of bronchitis, that its symptoms vary greatly 
in severity in different patients. It usually commences with more or 
less coryza. The symptoms are headache, flushed face, elevation of 
temperature, acceleration and fulness of pulse. In the mildest cases 
these symptoms are scarcely appreciable. The child is observed to 
sneeze and have some defluxion from the nostrils, and this is followed 
by an occasional mild, almost painless, cough, which declines in the 
course of a few days. The respiration and pulse are scarcely acceler- 
ated, and the appetite is but slightly impaired. There may be a little 
fretfulness, but the child is not confined to his bed or room, and usually 
amuses himself with his playthings. Auscultation in these mild cases 
reveals coarse mucous rales in the larger bronchial tubes, while the 
smaller tubes are free from mucus. Sibilant and sonorous rales are also 
observed, especially in the commencement of the bronchitis, at which 
time the secretion of mucus is suppressed or scanty. The cough in the 
commencement is for the same reason dry. It becomes looser by the 
second or third day, the sputum consisting of frothy mucus, with the 
admixture of pus and epithelial cells. The pus becomes more abundant 
as the disease continues. Expectoration from the mouth does not 
usually occur till after the age of four or five years ; under this age the 
sputum is ordinarily swallowed. 

The mild form of bronchitis described above, that in which only the 
larger bronchial tubes are affected, is common to all periods of infancy 
and childhood, but a severer grade of the disease is also of common 
occurrence, exclusive of those cases in which the minute branches of 
the bronchial tree are affected. It has already been stated that there 
is a tendency in bronchial inflammation to extend downward, and 
symptoms are proportionate in gravity to the degree of this extension. 
In severe bronchitis the pulse rises to 120 or 130 per minute, and the 
respiration is in a corresponding degree accelerated. The cough is 
frequent and painful, the pain being referred to the sternum, and often 
there is a steady dull pain in this region. The face is flushed and indi- 
cative of suffering, the temperature is considerably elevated, and the 
appetite is greatly impaired or lost. There is frequently an exacerba- 



598 BRONCHITIS. 

tion of symptoms in the latter part of the day. Depression of the infra- 
mammary region during inspiration, and dilatation of the alee nasi, 
accompany grave attacks of the inflammation. 

Auscultation in severe bronchitis reveals the presence of rales in all 
parts of the chest, sibilant and sonorous sparingly, coarse mucous and 
subcropitant more abundantly. 

General bronchitis or suffocative catarrh, the most dangerous form of 
this inflammation, is less frequent than bronchitis which is limited to 
the larger tubes, or to the larger tubes and those of medium size. It 
may commence quite abruptly, but ordinarily it results from the milder 
form of the disease. The symptoms at first are such as occur in the 
common form of bronchial inflammation, but instead of abating or 
remaining stationary, they gradually increase in severity till, suddenly, 
marked dyspnoea supervenes. The inflammation has now reached the 
minute tubes, and what promised to be an ordinary attack of bronchitis 
becomes one of great severity and danger. 

The respiration in severe bronchitis is short and hurried. Sixty to 
eighty inspirations per minute are not infrequent, while the pulse also 
is greatly accelerated, attaining as high a number as 140 to 160 or 
180 beats per minute. The cough is frequent, and the sputum, which 
collects in abundance, is expectorated with difficulty. If expectorated 
so as to be examined, it is found to consist largely of frothy mucus with 
epithelial cells. After a few days, if the patient live, it becomes more 
purulent. Sometimes, as in bronchitis of the adult, streaks of blood 
appear upon the mucus. In the first days of severe acute bronchitis, 
the temperature is considerably elevated, the face flushed and breathing 
oppressed. The patient is restless, moving from one part of the bed to 
another, seeking in vain for relief. The digestive function is impaired, 
as in all severe inflammations ; the tongue is moist and covered with a 
light fur; the appetite is nearly or quite lost. The infant takes the 
breast with difficulty, frequently relinquishing it on account of the 
dyspnoea ; older children take no solid food in consequence of the 
anorexia and the dyspnoea, and even drinks are swallowed hastily and 
apparently without relish, since deglutition interferes with respiration. 
On auscultation, in bronchitis of the minute tubes, sibilant, and after a 
day or two subcrepitant, rales are observed in every part of the chest. 
Percussion obtains a good resonance, unless the substance of the lung 
have become involved. As the disease approaches a fatal termination, 
the pulse becomes greatly accelerated, the respiration is also in a corre- 
sponding degree frequent and panting, the inspiration being accompa- 
nied by marked inframammary depression and dilatation of the alae 
nasi. The face becomes pallid, the prolabia livid, and the tips of the 
fingers livid and cool. The mucus and pus accumulating in the air- 
passages, increase more and more the obstruction to the entrance of air, 
and, finally, death occurs from apnoea. The nursing infant usually 
ceases to nurse for several hours before death, and a state of stupor 
commonly precedes the fatal event, due to the accumulation of carbonic 
acid in the blood. In young infants, especially those under the age of 
six months, not only in bronchitis of the minute tubes, but in severe 
ordinary bronchitis, I have often observed, toward the close of life, 



DIAGNOSIS. 599 

intermission in the respiration. It occurs after every six or eight or 
ten respirations, and equals in duration the time occupied in, perhaps, 
half a dozen respiratory movements. It is, therefore, an unfavorable 
prognostic sign, but some in whom it occurs recover by stimulation. 

The duration of acute bronchitis varies according to the extent of the 
inflammation. In the mildest form, the patient is convalescent after 
three or four days, and, in severer forms that terminate favorably, the 
disease begins, ordinarily, to decline by the close of the first week or in 
the second. The progress of bronchitis is somewhat more rapid in 
young children than in those of a more advanced age. When conva- 
lescence is fully established, it is not unusual for the cough to continue 
three or four weeks, though gradually declining. It is loose and pain- 
less, and is scarcely regarded by the patient. 

Death sometimes occurs as early as the second or third day in severe 
general bronchitis. The younger the infant, with the same extent and 
intensity of inflammation, of course the sooner the fatal result. The 
ordinary duration of fatal bronchitis is from six or eight days. If the 
patient pass beyond the tenth day, decline of the inflammation may be 
confidently expected, and recovery, unless there be a complication. 

Occasionally bronchitis becomes chronic, lasting several months before 
it entirely ceases. The chronic form may result from mild, as well as 
severe, bronchitis. The acute fever and accelerated respiration which 
characterize the acute affection abate, and the general health is nearly 
or quite restored; but an occasional cough continues, and the respira- 
tion is often audible, from the mucus which collects in the tubes, or 
from thickening of the mucous membrane. Sometimes there is mod- 
erate febrile movement, especially in the latter part of the day. On 
auscultation, coarse mucous, with perhaps sibilant and sonorous, rales 
are observed in the chest. 

There is great liability in chronic bronchitis to exacerbations. The 
disease often seems to be abating, and there is prospect of its speedy 
cure, when all the symptoms are intensified. The exacerbations are due 
to the fact that the bronchial surface, when it has been a considerable 
time inflamed, is very sensitive to the impression of cold. Even when 
the disease is entirely relieved, it is very liable to return by exposure to 
currents of air or changes of temperature. Chronic bronchitis occurs 
most frequently in the winter and in the spring and fall, when the 
weather is changeable, and is most intractable in these periods of the 
year. Many cases of chronic bronchitis are associated with dilatation 
of the bronchial tubes or with emphysema. The general health in this 
form of bronchitis, when not dependent on a tubercular deposit, ordi- 
narily remains good. Tubercular bronchitis, which is the result of a 
grave disease, does not require separate consideration. It is attended 
with emaciation, and is obstinate on account of the nature of the primary 
affection. It is due to the irritating effect of tubercular matter lying 
against the bronchial tubes.- 

Diagnosis. — Bronchitis can ordinarily be diagnosticated by the char- 
acter of the respiration and cough. The absence of hoarseness, stridu- 
lus inspiration, and croupy cough, excludes laryngitis ; and the absence 
of the expiratory moan and of the stitch-like pain on coughing, which 



JU ) 



600 BRONCHITIS. 

characterize pneumonia and pleurisy, excludes those diseases. Accurate 
diagnosis, however, can be most readily made by percussion and auscul 
tation. Examination of the chest enables us to state with positiveness 
not only the nature, but the extent of the affection. If the inflamma 
tion be confined to the larger bronchial tubes, coarse rales are discovered 
in them, while finer mucous rales are absent. If the bronchitis be in 
the minute tubes, subcrepitant rales are discovered in them. Percus- 
sion gives clear resonance on both sides, except in those instances in 
which collapse or pneumonia has supervened. 

Prognosis. — Bronchitis limited to the larger bronchial tubes, or to 
these and those of medium size, terminates favorably in a large majority 
of cases. Occasionally, severe inflammation, not extending to the smaller 
tubes, proves fatal in young infants, or those of feeble constitution. 
Bronchitis extending to the minute tubes, is, on the other hand, a dis- 
ease of great danger. It may be fatal at any period of childhood, but 
the younger and more feeble the patient, the greater the liability to a 
fatal result. Under the age of one year, it is one of the most fatal 
diseases of early life. 

The prognosis, in the commencement of all cases of bronchitis of 
average severity in the young child, should be guarded on account of the 
tendency of the inflammation to extend, as has been already stated in 
the preceding pages. After five or six days extension ceases, and if 
during that time no increase in the severity of symptoms occurs, the 
prognosis is favorable. Signs which indicate an unfavorable result are 
increasing frequency of pulse and respiration, difficult and scanty ex- 
pectoration, restlessness, a countenance expressive of suffering, and a 
progressively greater accumulation of mucus in the bronchial tubes, as 
determined by auscultation. Pallor and coldness of the face and extrem- 
ities, lividity of the tips of the fingers, rapid and feeble pulse, drowsi- 
ness, diminution of cough, while the mucus and pus accumulate in the 
bronchial tubes, and, in young children, intermissions in the respiration, 
indicate the near approach of death. Cases may, however, recover by 
proper treatment, although the symptoms are most unfavorable. 

It is unnecessary to mention the favorable prognostic signs of bron- 
chitis. This disease, when fully established, continues a certain number 
of days, whatever remedial measures are employed, and, if the symp- 
toms do not increase in severity during the first five' or six days, a favor- 
able result is highly probable. The prognosis in chronic bronchitis is 
ordinarily favorable, so far as life is concerned, provided that no ema- 
ciation occur. If there be emaciation, the bronchitis may be due to 
tubercles in the bronchial glands or lungs, and, of course, the prognosis 
is unfavorable. 

Treatment. — Bronchitis may be rendered much milder, and perhaps 
prevented by an emetic, employed in the first twelve or twenty-four 
hours, in conjunction with a warm bath. The physician is not, how- 
ever, ordinarily called sufficiently early to render this treatment effectual. 

Mild Bronchitis. — In mild bronchitis the inflammation is limited 
to the larger tubes, or to these, and those of medium size. Simple, 
soothing, expectorant, and laxative remedies are required in the treat- 
ment of this form of the disease. Mild counter-irritation may be pro- 



TREATMENT. 601 

duced by camphorated oil or the occasional application of a weak sina- 
pism, and one of the following mixtures may be given. The late Dr. 
James Jackson, of Boston, in his letters to a young physician, writes of 
the treatment: " For young children I employ the following: Take of 
either almond or olive oil, of syrup of squills, of any agreeable syrup, 
and of mucilage of gum acacia, equal parts, and mix them. Of this 
mixture a teaspoonful may be given to a child at two years of age ; a 
little less if younger, and increased if older, so as to double the dose to 
one in the sixth year. This may be given from three to six times in 
the twenty-four hours. Sometimes a little opiate must be added at 
night to appease the urgent cough." Another good medicine is the 
mistura glycyrrhizaa composita, half a teaspoonful of which should be 
given every two hours to a child of three years, and one teaspoonful to 
one of six years. The syrupus ipecacuanhas compositus of the French 
pharmacopoeia, the contre de la toux, consisting of ipecacuanha, senna, 
thyme, poppy, sulphate of magnesia, orange flower water, wine, water, 
and sugar, being soothing and slightly laxative, is also an useful remedy. 
These cases also do well with simple mucilaginous drinks and confinement 
in a warm room. 

Bronchitis affecting the Medium Size or Smallest Tubes. — 
The use of leeches has been, for the most part, abandoned in the treat- 
ment of bronchitis, not only in infancy, but at all ages. The applica- 
tion of dry cups over the sternum is recommended by some judicious 
physicians as a proper remedy for bronchitis in infancy as well as child- 
hood, and the use of the wet cup is even advocated for robust infants in 
the commencement of the inflammation ; but the beneficial effects of its 
use can be obtained by other measures which preserve the strength, and 
are therefore preferable. 

Local treatment applied to the chest in bronchitis is important, since, 
if properly made, it increases the comfort, and obviously diminishes the 
intensity of the inflammation. Henoch, whose ample experience and 
sound judgment command attention, if not acceptance of his views, says 
of local treatment : "I strongly advise hydropathic applications to the 
chest from the neck to the umbilicus. A napkin or diaper is dipped in 
water at the temperature of the room, well wrung out, and then placed 
around the chest, without exercising any compression, so that the arms 
are free ; this is surrounded by a roll of batting, and then covered by a 
layer of oil silk or gutta-percha paper. When the fever is high these 
applications should be renewed at least every half hour ; later they may 
be kept for one or even two hours, and this continued for several days 
and nights. I have occasionally continued it for a week, the cool water 
being changed to a temperature of 26° to 27° R." 

The benefit derived from the cold water application is, according to 
Henoch, threefold : first, the deep inspiration which the application of 
cold causes, thus expanding portions of the lungs which are liable to 
atelectasis ; secondly, " derivative irritation of the skin ;" and, thirdly, 
the production of moisture in the air surrounding the child, which he 
inhales. Deep inspirations are, in my opinion, caused to a greater 
extent by medicines which excite cough, as ammonia, and warm appli- 
cations certainly produce more derivation to the surface than cold. 



602 BRONCHITIS. 

One benefit from the application of cold Henoch does not allude to, and 
that is the reduction of temperature. But I prefer for this purpose 
frequent sponging of the upper extremities and face with cold water, 
and perhaps its constant application to the head. I have observed 
marked relief from this use of cold water. 

For years in my practice the following external treatment has been 
employed with apparent benefit in nearly every case. For infants 
under the age of three months, who have accelerated respiration and 
painful cough indicating the need of external treatment, two poultices 
of ground flaxseed are prepared, covered by thin muslin, and made so 
moist that they wet the hand in holding them. They are made as thin 
as the pasteboard cover of a book, and of such a size, that applied in 
front and behind they cover the entire chest. Camphorated oil is 
smeared over their under surface three or four times daily, and over 
their exterior oil silk is applied. For infants over the age of six months 
I prefer poultices of the following : 

R. — Pulv. sinapis . . . . . . . . . ?j. 

Pulv. seminis lini l xv j- 

The poultice, to give most relief, should be so wet as to cause constant 
moisture of the surface, and so irritating as to cause constant redness, 
without necessitating its removal. Vesication should never be produced. 
Flannel wrung out of warm water made slightly irritating by mustard, 
and covered by oil silk, also answers the purpose. External treatment 
should be employed in most instances so long as the respiration is hur- 
ried and cough painful. During the stage of convalescence, instead of 
the poultice, cotton wadding or batting around the chest increases the 
comfort and prevents taking cold. Derivation to the surface, early 
made and continued, tends to check the downward extension of bron- 
chitis. Often improvement in the symptoms is observed, especially less 
dyspnoea and restlessness, immediately on the employment of the local 
measures recommended above. 

Internal Treatment. — Medicines are indicated which have a ten- 
dency to diminish the inflammation, to prevent its downward extension 
to the minute bronchial tubes, and to promote expectoration. The 
bowels should be kept open in all cases of bronchitis. For robust chil- 
dren, at or over the age of six months, the following prescription is 
useful in the commencement of the attack : 

R. — Syr. ipecac, 

Spts. aether, nitr. . . . . . aa ^ij. 

01. ricini . . . . . . . . . giij. 

Syr. bal. tolut 3J. — Misce. 

Dose, half a teaspoonful to one teaspoonful, every second hour, for the age of one 
to two years. 

This prescription is, I think, preferable to the following, recom- 
mended by Henoch : 

R . — Hyd. chlor. mitis 

Pulv. rad. ipecac. .... 0.01 

Sacch. alb. . . . . 20.00 

To he given every two hours. 



INTERNAL TREATMENT. 603 

But the medicinal agent which experience has shown to be the most 
useful in the bronchitis of children is one of the salts of ammonium. In 
the treatment of infantile bronchitis depression must be avoided. The 
cough should be strong and frequent, for the chief danger occurs from 
the accumulation of viscid mucus in the minute tubes so as to obstruct 
the entrance of air into the alveoli, leading to atelectasis, and causing 
the dyspnoea which is so painful and prominent a symptom in this dis- 
ease. Ammonium carbonate or muriate, better than any other agent, 
promotes expectoration by exciting cough, and rendering the mucus 
less viscid, and it does not reduce the strength. When anxious parents 
ask me to prescribe something to relieve the cough, I reply that the 
more frequent the cough the better it is for the infant, since it affords 
the means of freeing the tubes from the accumulating mucus. For- 
merly I prescribed largely the carbonate, but Dr. Northrup, Curator 
of the Is ew York Foundling Asylum, has found evidences of gastritis in 
the stomachs of infants who have perished from various diseases, for 
which the carbonate was administered. Since informed of this I have 
prescribed the muriate. The ammonium muriate may, in most instances, 
be given with benefit from the commencement, in both mild and severe 
bronchitis in infants under the age of one year. The following is a 
convenient formula for its employment : 

R. — Ammon. muriat. ........ zj. 

Syr. bal. tolut £ij. — Misce. 

The ammonium carbonate should be prescribed dissolved in water, 
and given to the patient in milk. 

Fifteen drops contain one grain, the dose at the age of three months. 
Five drops should be given at the age of one month, and thirty at the 
age of six months, in a little water. This expectorant should be given 
frequently, as every half hour or every hour in cases of severity. The 
urgent symptoms are relieved by free expectoration, which this medi- 
cine more than all others which I have employed tends to produce. It 
should be given night and day, at the short intervals mentioned, until 
amelioration of symptoms occurs. The benefit from its use is most 
apparent under the age of eighteen months, or at the age when capil- 
lary bronchitis and atelectasis are most liable to occur. 

Medicines which exert a greater controlling effect on the action of 
the heart than those which we have mentioned, are often required during 
the progress of severe "bronchitis." If the patient give evidence of 
declining strength while the pulse is unusually rapid and the tempera- 
ture elevated, quinine given in moderate doses, as two grains every fourth 
hour to a child of two years, has seemed to me useful as a heart tonic. 
The tincture of digitalis in doses of one to two drops every second hour 
for infants between the ages of six months and two years, is also useful 
as a heart tonic. In a case recently under treatment by Dr. Jacobi 
and myself, the infant, aged twenty-three months, having a temperature 
varying from 102J° to 105J°, respiration 82 to 105, and pulse 165 and 
higher, took four drops of tincture of digitalis, besides the quinine and 
ammonium muriate, three days ; with apparently a good result from the 



604 BRONCHITIS. 

digitalis. This remedy was afterwards continued in two-drop doses, 
and the patient recovered. 

For robust children over the age of two years, in the commencement 
of acute bronchitis, having a full and strong pulse and flushed cheeks, a 
cardiac sedative is required. The following will be found a useful recipe 
for such a patient at the age of five years : 

R. — Tinct. rad. aconit gtt. xvj. 

Syr. scillae composit. . . . . . . zij. 

Syr. bal. tolut. 5 x i y - — Misce. 

Dose, one teaspoonful from two to four hours. 

The medicine should be omitted or given at longer intervals, if the 
frequency of the pulse be reduced. Veratrum viride, on account of its 
very depressing action is not so safe a remedy as aconite. In children 
of this age the muriate of ammonium is also required as an expectorant ; 
it may be given between the doses of the above mixture, and when the 
latter is discontinued it should be given as the main remedy. 

When and how to employ opiates, to procure the needed rest in the 
bronchitis of children, should be carefully considered. We have stated, 
that a frequent and strong cough is required in the infant in order to 
prevent clogging of the minute tubes with muco-pus, and to prevent 
atelectasis. Still, some respite from the cough if it be frequent, is re- 
quired to prevent exhaustion. I prefer for young infants to give the 
opiate separately from the expectorant, and only occasionally, as they 
may need sleep. The following is a useful formula for an infant of six 
months who is restless and without the proper amount of sleep : 

R . — Liq. opii composit. (Squibb) .... 

Potas. bromidi 

Syr. rubi idsei (raspberry) .... 

Aquae 

Dose, one teaspoonful when needed. 

Eight drops of paregoric may be given in place of the above. Twice 
the dose of either of these opiates is sufficient at the age of twelve 
months. For older children, Dover's powder — an eligible form of 
which is Squibb's liquid Dover's powder, the tinctura ipecacuanhse 
composita — is a useful remedy to procure sleep, one minim of which 
corresponds to one grain of the powder. 

During convalescence medicines should be administered less and less 
frequently, or in smaller doses. Emetics in ordinary cases of bronchitis 
are not required, except in the commencement. In severe bronchitis, 
however, especially when the smaller tubes are inflamed, they sometimes 
appear to be useful. The cases which may need their adminstration are 
those in which mucus and pus collect in the tubes more rapidly than 
they are expectorated, so as to give rise to urgent dyspnoea. An emetic 
administered under such circumstances may give prompt and decided 
relief. The object to be gained is obviously very different from that in 
the commencement of bronchitis, and such agents should be employed 
as act promptly with little depression. Ipecacuanha is probably the 
best emetic for this purpose. 

Infants oppressed by the accumulation of mucus and pus may some- 
times be relieved by tickling the fauces with the finger. This provokes 




ATELECTASIS. 605 

vomiting, and the viscid mucus which collects at the entrance of the 
glottis is removed by the finger. 

The diet should, as a rule, be nutritious through the entire disease ; 
but robust patients, or those who have ordinary health, if over the age 
of two years, and affected with primary bronchitis, are sufficiently 
nourished by light diet, chiefly farinaceous, in the first days of the 
attack, after which animal broths are proper. Whatever food is given 
in severe bronchitis must be in the form of drinks, since the appetite is 
lost, while the thirst is such that liquids are less likely to be refused. 

In primary bronchitis, if mild or of ordinary severity, alcoholic stimu- 
lants are not required. In secondary bronchitis they are often needed, 
and also in severe primary bronchitis, if there be dyspnoea with evidences 
of prostration. In the infant two drops of brandy for each month in 
the age, given every second hour, enable the child to expectorate with 
more freedom and less exhaustion. 



CHAPTER V. 

ATELECTASIS. 

In certain newborn infants the lungs do not undergo inflation, or only 
a portion of the lobules is inflated, to wit, those in the upper lobes, 
while the remainder of the organ continues unchanged from the foetal 
state. This non-inflation of the lung is designated congenital atelec- 
tasis. It is apparently not due, unless in rare instances, to defective 
formation of the respiratory apparatus, for at the autopsies of cases 
which have ended fatally, as most cases do, at an early period, insufflation 
is easy, there being no occlusion of the air-passages, nor unusual adhe- 
sion of the walls of the alveoli to prevent the admission of air. Physi- 
cians have believed that in some instances they discovered the cause in 
an enlarged thymus gland, which compressed the lower part of the 
trachea, but this cause has not seemed to exist, or was exceptional, in 
cases which I have observed, for although the thymus at birth is large, 
having nearly the size of an unexpanded lung, it has not seemed to me 
to be unduly enlarged in most atelectatic cases which I have examined 
after death. 

The ordinary proximate cause of atelectasis neonatorum is feebleness 
of inspiration, whether due to general debility, as in infants born per- 
maturely, or weakened by placental hemorrhage in the last months of 
foetal life, or, as is frequently the case, to injury of the brain and conse- 
quent impairment of the function of the pneumogastrics during birth. 
I have more fully treated of this form of atelectasis in the chapters which 
relate to the maladies incidental to the birth of the child, and to these 
the reader is referred. 



606 ATELECTASIS. 

Acquired Atelectasis, or collapse of lung, is less extensive than 
congenital atelectasis, being confined to a portion of a lobe, and often to 
only a few lobules. It occurs chiefly during the period of infancy and 
in feeble children. It is a common malady, in foundling asylums, in 
wasted infants who perish before the close of the first year. I have fre- 
quently at the autopsies of such infants observed it along the thin in- 
ferior margins of the lower lobes, and in the tongue-like prolongation of 
the left upper lobe. In this class of cases, catarrh of the bronchial tubes 
appears to have little or no agency in causing the collapse. The cause 
is found in the impaired functional activity of the lungs. In the state 
of debility the heart beats feebly and the stream of blood from it to the 
lungs is small and slow, so that the inspiration of a small amount of air 
suffices for its decarbonization. The inspirations also are seen to be 
feeble, causing little expansion of the walls of the thorax. Conse- 
quently the entire lung is imperfectly inflated, as is seen in fatal cases, 
but the distant thin portions of the organ are least expanded. These 
receiving little or no air, soon begin to contract from the presence of the 
elastic tissue, and collapse or atelectasis ensues. 

This has been the most common form of atelectasis in cases of this 
malady, which I have observed in foundling asylums, and it probably 
occurred in the manner which I have described. 

Another cause of acquired atelectasis to which all writers allude is 
bronchial catarrh, which commencing in the larger tubes extends down- 
ward into those of smallest size. By the swelling of the mucous mem- 
brane, and the accumulation of viscid muco-pus which cannot be expec- 
torated, certain of these tubules become occluded, so that the inspired 
air is shut oif from the alveoli situated beyond them. Occlusions are 
obviously most likely to occur in the bronchitis of feeble infants, whose 
cough has little expulsive force, so that debility is also a factor in the 
production of this form of atelectasis. The portion of lung withdrawn 
from the respiratory function soon collapses, the air which it contained 
being probably in part expired, but chiefly absorbed. 

Atelectasis is not, however, so important or frequent a complication 
of bronchitis as was formerly supposed, for catarrhal pneumonitis due to 
extension of the inflammation from the bronchioles into the lung has 
been mistaken for it. Solid non-crepitant nodules or portions of lung 
are frequently observed at the autopsies of infants w T ho have perished of 
severe bronchitis, and these may be atelectatic or pneumonic, but they 
are more frequently the latter than was formerly supposed. 

The possibility of insufflating these solid portions when removed from 
the body after death, was till within a few years regarded as decisive 
proof of atelectasis. It is now known that this is not a reliable test, 
since a lung solidified by recent catarrhal pneumonitis can be almost as 
readily inflated as one which is collapsed;, but the inflated pneumonic 
lung is more solid and resisting when pressed between the thumb and 
fingers than is the collapsed lung. The decisive proof is afforded by 
the microscope, by which cell-proliferation is discovered within the 
alveoli in catarrhal pneumonitis, while it is lacking in simple collapse. 
An increase of the dyspnoea not infrequently occurs in severe infantile 
bronchitis, without either pneumonia or collapse from the accumulation 



ANATOMICAL CHARACTERS. 607 

in the bronchioles of the secretion which is with difficulty expectorated, 
but if dulness on percussion and other physical signs indicate solidifica- 
tion of the lung at some point, of course pneumonia or collapse has 
occurred. If a sufficient amount of lung be involved to produce well- 
marked physical signs the disease is in most instances pneumonia and 
not collapse, though it may be the latter. Both these pathological states 
may, however, occur in the same lung as complications of severe bron- 
chitis. The severe paroxysmal cough of pertussis, especially when 
accompanied by considerable secretion, frequently produces collapse of 
portions of the lower lobes, while it causes emphysema in the upper 
lobes. 

Symptoms. — Atelectasis resulting from bronchitis gives rise to no 
new symptoms. So far as it has any appreciable effect it aggravates 
certain symptoms of the primary disease, but as it is ordinarily limited 
to a small area this effect is not very marked. When a bronchial tube 
is so occluded by muco-pus that the alveoli with which it communicates 
collapse, there is ordinarily, at the same time, more or less accumulation 
of this secretion in other tubes throughout the lungs. Therefore, the 
entrance of air into the alveoli with which these tubes communicate is 
slow and difficult, but usually without complete obstruction, and with- 
out true atelectasis, but with a semi-collapse such as we observe in fatal 
croup. This explains the dyspnoea which is present in these cases. If 
the secretion be expectorated from these tubes the dyspnoea abates, even 
if the plug which has completely occluded a tube and the consequent 
atelectasis remain. 

Atelectasis occurring in wasted and feeble infants, in consequence of 
the diminished force of the inspirations, does not in most instances give 
rise to any prominent symptom, since it occurs chiefly in distant thin 
portions of the lungs. I have observed an occasional short, nearly 
painless cough in such infants, when the autopsy revealed no pulmonary 
lesion except the atelectasis. 

Anatomical Characters. — The portion of lung which is affected 
with recent atelectasis has a dark brown or dark bluish color. It is de- 
pressed below the general level of the lung, is firm and non-crepitant on 
pressure and its incised surface is smooth. HyperBemia supervenes, for 
a portion of lung in which the circulation continues, but from which air 
is excluded, becomes congested. In acquired atelectasis the congestion 
is especially marked, since the vessels which have been adapted by 
growth for a larger area are compressed into one of smaller extent, so 
that they become tortuous and bulging within the lumina of the alveoli, 
while the free flow of blood through them is retarded by the constriction 
of the elastic fibres of the lung. An obvious and certain result of the 
hyperemia is the transudation of serum into the alveoli, producing 
oedema. This union of pulmonary hyper semia with oedema by which 
air is excluded from the alveoli constitutes the state known to patholo- 
gists as splenization, and in proportion as it occurs the lung depressed 
by the atelectasis rises toward the general level. It may even rise^above 
it, and .it now has a doughy elastic feel. The pathology of these oede- 
matous atelectatic spots, heretofore obscure, has been clearly explained 
by Rindfleisch. 



608 ATELECTASIS. 

If the patient live, and the atelectatic lobules do not soon return to 
a state of health, they undergo further changes. Rindfleisch says: 
"From the series" (of changes, provided inflammation do not occur) 
" we especially render prominent two conditions, inveterate oedema and 
slaty induration. But inflammation does commonly occur after a time 
in a collapsed lung." Those who are familiar with the post-mortem 
examinations of infants will fully agree with Rindfl eisch when he says : 
u Splenization, quite generally taken, appears to present extraordinarily 
favorable preliminary conditions for the occurrence of inflammatory 
changes. It may directly represent the initial hyperemia of acute in- 
flammation, and be followed by lobular and lobar, but constantly catar- 
rhal infiltrates." It is well known by pathologists that protracted con- 
gestion, active or passive, of whatever organ or tissue, is very liable to 
pass from a state of simple stasis of blood to one of cell-proliferation, 
and the atelectatic lung, as I have myself observed at autopsies, affords 
a common example of this. I have several times made or have pro- 
cured microscopic examinations of the atelectatic portions of lungs of 
infants who had died, for the most part, in a wasted and enfeebled state, 
and have found in them clear evidence of the presence of a catarrhal 
pneumonia. The interesting fact therefore must be recognized, that 
atelectasis frequently passes to a state of inflammation, so as to present 
the characters of ordinary hypostatic pneumonia, and no doubt undergo 
the same subsequent changes. 

Atelectasis, when recent and simple or uncomplicated, may soon dis- 
appear by the expectoration of the obstructing secretion, if such be 
present, or if there be no obstruction, by increased force of inspiration. 
If it do not soon disappear it undergoes one of the ulterior changes 
alluded to above, and henceforth the symptoms and history are those of 
the new malady which has supervened. 

Treatment. — The treatment of acquired atelectasis is simple. If it 
be recent and there be evidence that it is clue to the accumulation of the 
secretion in the bronchial tubes, an emetic, which acts promptly and 
with the least possible depression, may be very useful. It is especially 
indicated if there be little or no pneumonia, the strength not greatly 
reduced, and there be dyspnoea with insufficient decarbonization of blood 
in consequence of the abundance of the secretion in the smaller tubes. 
An emetic which acts promptly and with little prostration may aid 
greatly in establishing the respiratory function in collapsed lobules, by 
expelling the obstruction, and producing a freer and deeper inspiration. 
One of the best if not the best emetic for this purpose is sulphate of 
copper, given in a dose of one or two grains to a child of one year. 
With or without the use of the emetic our main reliance must be on sus- 
taining and stimulating measures, by which the cough, the cry, and the 
inspirations acquire more volume and force. Most cases require alco- 
holic stimulants and the ammonium carbonate. Rubefacient applica- 
tions to the chest are also commonly employed, and are probably useful. 



PNEUMONITIS. 609 



CHAPTEE VI. 

PNEUMONITIS. 

In children over the age of three years, pneumonitis differs but little 
in form or phenomena from that of the adult, being Ordinarily primary 
except as it depends on an irritant, as tubercles, and extending rapidly 
over one or more entire lobes. It is the form of pneumonia which is 
designated lobar or croupous. In those under the age of three years 
pneumonia is, on the other hand, as a rule, secondary to bronchitis. It 
is produced by extension of the inflammation from the bronchial tubes 
into the alveoli, and it affects certain lobules instead of an entire lobe. 
It is designated catarrhal or lobular pneumonitis. In catarrhal and 
croupous pneumonitis, the solidification of the lung and exclusion of 
air are due mainly to the newly formed cellular elements with which 
the alveoli are filled, though these cells differ in the two diseases. In- 
terstitial pneumonitis consists in an inflammation and hyperplasia of the 
connective tissue of the lungs. It is the chronic pneumonia of authors, 
resembling in many respects, in its anatomical and clinical characters, 
cirrhosis of the liver. The inflammation which produces this result is 
subacute, and -in nearly all cases is dependent on some persistent local 
disease in the minute bronchial tubes or lungs, as softened or cheesy 
tubercles, cancer, abscesses, protracted inflammation of the alveoli or 
bronchioles, whether produced by the inhalation of dust of an irritating 
nature or other cause. Interstitial pneumonia is much more rare in 
children than adults, and, as it presents no peculiar features in them, it 
need only be alluded to in this connection. 

Causes. — Croupous pneumonitis in most cases results from that com- 
mon cause of inflammations — namely, taking cold. It commences as a 
primary disease within a few hours after exposure. Catarrhal pneu- 
monitis, on the other hand, commonly results from antecedent patho- 
logical states, which we will enumerate. 

First. Most cases of capillary bronchitis, as we have stated above, result 
from bronchitis. The inflammation extending downward engages the 
minute bronchial tubes, and from them traverses the alveoli of one or 
more lobules. This is the broncho-pneumonia of children described by 
authors ; it occurs most frequently between the ages of six and eighteen 
months. 

Secondly. Hypostasis, or passive congestion, is an important factor 
in the causation of many cases, and in feeble infants it is not infre- 
quently the sole cause. Infants with feeble health and languid circu- 
lation, lying in their cribs day after day with little movement of the 
body, are very liable to passive congestion of the depending portions of 
their lungs, and this by and by eventuates in a cell-proliferation within 
the alveoli — in other words, a pneumonia presenting some peculiarities, 



(310 PNEUMONITIS. 

but of the catarrhal form. In foundling hospitals, where feeble infants 
are received and treated, this is one of the most frequent pathological 
states, and is the prevailing form of pulmonary inflammation. It is 
sometimes described as hypostatic pneumonia. Hence physicians whose 
observations have been largely in such institutions, have almost ignored 
any other form of pneumonia in infants. Billard, a close and accurate 
observer, wrote nearly half a century ago: "Pneumonia of infancy 
presents peculiar characters, in which it differs fi-oni the same affection 
in adults. Instead of being an idiopathic affection arising from irrita- 
tion developed in the pulmonary tissue under the influence of atmos- 
pheric causes, which often excite the disease, the pneumonia of young 
infants is evidently the result of a stagnation of blood in their lungs. 
Under these circumstances this blood may be regarded as a kind of 
foreign body. . . . . It would, therefore, appear that inflamma- 
tion of the lungs, which produces hepatization, arises in infants, in gen- 
eral, from some mechanical or physical cause." Valleix also states that 
he found the lesions of pneumonia in a majority of the infants who died 
in the Hopital des Enfants Trouves. The statements of Valleix are 
applicable also to the Infants' Hospital, the Foundling Asylum, and 
Nursery and Child's Hospital, of this city, as regards those cases in 
which death results from chronic disease. We shall see hereafter that 
hypostatic pneumonia is one of the most common complications of chronic 
infantile entero-colitis, the summer complaint of the cities. 

Thirdly. Catarrhal pneumonia of infants sometimes results from col- 
lapse. It is not unusual to find, at the autopsies of infants who have 
died in a state of emaciation and feebleness, portions of the lungs remote 
from the bronchi collapsed, as, for example, the thin edges of the inferior 
lobes, and the tongue-like process of the upper lobe, the process which 
lies over the heart. The immediate cause of the collapse has been a 
bronchitis, or it has resulted directly from the general weakness of the 
infant, and its feeble respirations. Now, a collapsed lung soon becomes 
the seat of passive congestion. The functional activity of an organ 
favors circulation through it, and if the function be abolished the flow 
of blood in the part is retarded, and stasis more or less complete results. 
The hypersemic state of collapsed pulmonary lobules presents the same 
anatomical condition, for the supervention of pneumonia, as occurs in 
cases of hypostatic congestion. Consequently, cell-proliferation soon 
begins in the collapsed alveoli, the volume of the affected lung in- 
creases, and it becomes firmer and more resisting to the touch, and the 
microscope reveals the characters of a subacute but genuine catarrhal 
pneumonitis. I have made or have procured microscopic examinations 
of a considerable number of such specimens, and have found the alveoli 
more or less filled with cells of the epithelial character. (See article 
Atelectasis.) 

In rare instances in infancy and childhood pneumonitis results, as it 
more frequently does in the adult, from an embolus detached from a 
clot, which had formed in some remote vein, in consequence of arrest 
of circulation in it, by inflammation of the contiguous tissues. This 
is described by writers as a distinct form of pneumonitis, designated 
embolic or embolismal. A specimen showing this mode of causation 




ANATOMICAL CHARACTERS. 611 

was exhibited by me at the New York Pathological Society, in Feb- 
ruary, 1868. An infant, born January 22, 1868, of strumous parents, 
had been fretful, but without appreciable ailment till February 3d, when 
inflammation of the connective tissue occurred on the anterior aspect of 
the left leg, a little below the knee. 
This extended downward, suppurated, IG * 

and the pus was evacuated February 
5th. In the mean time three other sim- 
ilar inflammations occurred, two on the 
right foot and leg, and the other over the 
parietes of the chest in the right infra- 
mammary region. Suppuration occurred 
in all of these. 

On February 8th this infant was sud- 
denly seized with extreme dyspnoea, and 
died in a few hours. Numerous minute 
puriform collections (formerly called me- 
tastatic abscesses) were discovered in each lung, most of them scarcely 
larger than a pin's head. One of them on the right side in the middle 
lobe connecting with a bronchial tube had ruptured into the pleural 
cavity, causing pneumothorax, collapse, and incipient pleuritis. 

The annexed figure exhibits the microscopic appearance of this soft- 
ened fibrin, which, to the naked eye, so closely resembled pus. 

On account of the speedy death, the emboli had produced in the 
lobules where they had lodged little more than congestion or the first 
stage of pneumonitis around them- Had the infant lived longer, doubt- 
less the ferments or the vibriones, which some consider the irritating 
element of emboli, would have caused a greater amount and more 
advanced stage of pneumonia. 

Anatomical Characters. — Nothing need be added in this connec- 
tion to what has already been said, in reference to interstitial and embo- 
lismal pneumonias. Being comparatively rare in children, they present 
the same anatomical characters as in the adult. That unimportant form 
of pneumonia called pleurogenous, and which consists in a croupous 
inflammation of the superficial infundibula of the lung underneath an 
inflamed pleura, occurs in children as well as adults. Being secondary 
to the pleuritis, and produced by extension of the inflammation of the 
pleura, it gives rise to no appreciable symptoms, on account of its slight 
extent, and as it presents no peculiar features in the child it need only 
be alluded to. 

Croupous pneumonitis, which we have stated is the ordinary form 
of pulmonary inflammation in children over the age of five years, has 
the same anatomical characters as in the adult. It ordinarily involves 
an entire lobe. It is more frequent in the right than left lung, and in 
whichever lung it occurs its most frequent seat is the lower lobe. The 
inflammation may, however, be limited to an upper lobe, especially on 
the right side. It ordinarily commences near the root of the lung, and 
extends forward. 

Croupous pneumonitis presents three stages, that of congestion, red 
hepatization, and gray hepatization. In the stage of congestion the 



612 PNEUMONITIS. 

capillaries in the walls of the alveoli are greatly distended, bulging for- 
ward in loops within the alveolar spaces so as to diminish them, and a 
viscid albuminous fluid begins to exude, in which points of extravasated 
blood appear. The affected lung in this stage has a deep red color, its 
elasticity is greatly diminished, and its density and weight increased. 
On account of the reduced size of the alveoli from the bulging of the 
alveolar walls, and the viscid fluid within the alveoli and terminal bron- 
chial tubes, the function of the affected lobe is nearly lost, and hence 
the dyspnoea which patients experience in the first stage of the inflam- 
mation. 

The second stage is characterized by the continued and increased 
escape of the liquor sanguinis and red and white corpuscles through the 
stigmata or little apertures which exist normally in the walls of the capil- 
laries. The inflamed alveoli and the minute bronchial tubes which 
terminate in them are filled with this pneumonic exudation. The rela- 
tive proportion of the elements of the blood in the exudate varies in 
different cases. Fibrin is always present, immediately coagulating in 
delicate filaments within the interstices of which the corpuscles are 
lodged. The white corpuscles in some cases are much in excess of the 
red, while in others the red predominate. The lung in the second stage 
contains no air, has a greater specific gravity than water, is friable so as 
to be readily torn and penetrated by the finger. The torn surface in 
the adult presents a granular appearance, each granule being the con- 
tents of an air-cell. In the child the granules are not distinct on ac- 
count of the small size of the air-cells, but the volume of the inflamed 
lobe is somewhat increased as in the adult. 

The stage of gray hepatization succeeds, in which the volume of the 
lung is still greater. The change of color is due partly to compression 
of the capillaries by the inflammatory material, partly to destruction of 
the red corpuscles, and disappearance to a greater or less extent of their 
coloring matter, while the white corpuscles (pus-cells) remain, but it is 
due more to commencing fatty degeneration in the exudate prior to its 
liquefaction. In favorable cases the lung soon returns to its normal 
state, the liquefied substance which filled the alveoli being in part ab- 
sorbed, in part expectorated. 

Croupous pneumonitis often causes inflammation of the portion of the 
pleura which covers it. Pleuritis developed in this way is circum- 
scribed, but it frequently extends beyond the inflamed parenchyma to 
the distance of one or two inches. Bronchitis is also a common accom- 
paniment. It may be general, in which case it occurs independently, 
or be limited to the tubes lying within the inflamed lung, in which case 
it results like the pleuritis from the pneumonitis. It is seen from this 
description that the pus-cells which are produced so abundantly in the 
alveoli are believed to be chiefly exuded white corpuscles of the blood. 
Possibly some of them may be produced by proliferation of the epithelial 
cells which line the alveoli, in the same manner as they are believed to 
be produced in the bronchial tubes. 

Catarrhal pneumonitis, which is, as we have stated, for the most part 
the lobular pneumonitis of writers, and which, with an occasional 
exception, is the form of inflammation in children under the age of 



ANATOMICAL CHARACTERS. 613 

three years, presents not only clinical but anatomical features, which 
distinguish it from the croupous form of the disease. Those who have 
witnessed few post-mortem examinations of young children, and whose 
views of the lesion are influenced by the expression lobular, suppose 
that there is an alternation of inflamed and healthy lobules, so that the 
surface of the lung presents an appearance not unlike mosaic work. 
This is a mistake. Although an entire lobe is seldom inflamed, as in 
croupous pneumonitis, the inflammation commonly extends over more 
or fewer contiguous lobules, but we find certain lobules in the midst 
of the inflamed area which are but slightly affected or have escaped 
entirely. The extent of the inflammation is ordinarily from one to three 
inches, but I have seen a nodule of true catarrhal pneumonia not larger 
than a pea, while every other portion of the lung was healthy. On the 
other hand, almost an entire lobe may appear hepatized to the naked 
eye as in the croupous inflammation, but by a careful examination cer- 
tain lobules will be found unaffected. Thus, in a case in the Nursery 
and Child's Hospital, in which death occurred at the age of one year 
from pneumonitis supervening upon pertussis, an entire lobe, with the 
exception of a little of its anterior border, presented the appearance and 
feel of red hepatization, but a careful microscopical examination 
revealed not only the absence of fibrin in the exudate, showing the 
catarrhal nature of the inflammation, but also certain lobules in the 
midst of the inflamed lung, which were not involved. Prof. Delafield, 
who has made careful microscopic examinations of inflamed lobules in 
catarrhal pneumonia resulting from extension of the inflammation from 
the bronchial tubes, says : "In some cases the air-vesicles are filled 
principally with pus ; in other cases almost entirely with epithelial 
cells ; in other cases with both pus and epithelium ; in others with pus, 
epithelium, and fibrin." 

Inflammation of the pleura over the inflamed lung is less frequent in 
this disease than in croupous pneumonia. The seat of catarrhal pneu- 
monia is ordinarily the posterior part of the lungs, even when it results 
from extension of the inflammation from the bronchial tubes. When 
resulting from collapse, it affects chiefly those lobules which are remote 
from the bronchi, and which the air enters only by a long circuit. 

Catarrhal pneumonitis, when it arises from extension of acute in- 
flammation of the bronchioles, is acute, but in those forms of the disease 
which supervene upon passive congestion it is subacute. The alveoli are 
less distended by inflammatory products than in croupous pneumonia, 
not only from the less amount of fibrinous exudation, but also of cells. 
Hence the volume of the inflamed lung is not so great as in that disease, 
and the torn surface, even in the adult, does not present so distinct a 
granular appearance. Hence, also, the stage of gray hepatization does 
not supervene so uniformly and regularly, since there is less compres- 
sion of the capillaries in the alveolar walls, and the mutual pressure of 
the inflammatory products is less. In infants who have died with this 
form of pneumonitis, of six or eight weeks' duration, it is not unusual 
to find the affected lobules still in the stage of red hepatization. Cell- 
proliferation occurs in the bronchioles of the inflamed lung as in the 
alveoli, producing within them numerous plugs, which, though they ob- 



614 PNEUMONITIS. 

struct the entrance of air, are not so firm as in croupous pneumonitis, 
since they contain less fibrin. 

In favorable cases the lung affected by catarrhal inflammation returns 
to its normal state, probably by the same process as in croupous pneu- 
monitis. In other cases, especially in scrofulous and feeble children, 
the inflammation, instead of resolving, passes into what is now desig- 
nated cheesy, or by certain writers scrofulous, pneumonitis. 

Cheesy Pneumonitis. — Cheesy degeneration of the inflammatory 
product occasionally occurs in the croupous form of inflammation, but it 
is more common in the catarrhal. I have most frequently observed it 
in New York during epidemics of measles, when this form of pneumo- 
nitis supervened upon the catarrhal bronchitis of that disease. Cheesy 
pneumonitis is in its nature chronic, and attended with great reduction 
of the vital powers. 

Cheesy degeneration of the exudate or infiltrate consists essentially 
in the absorption of the liquid portion, and fatty degeneration of the 
solid. The obstruction of the circulation in the capillaries and the ac- 
cumulation of cells in the alveoli and bronchioles which cannot be ex- 
pectorated, are conditions which favor cheesy metamorphosis. The 
appearance and consistence of the lung when it has undergone this 
change are well expressed by the term which is employed to designate 
it. The cheesy mass consists of fatty, shrivelled, and fragmentary 
cells, and amorphous matter in which can be traced the elastic fibres 
and larger vessels of the parenchyma, the other histological elements 
having disappeared. , 

The caseous mass after a time softens, attracting moisture from the 
surrounding tissues. The molecular detritus and the shrivelled cells are 
now suspended in a liquid, and, like any dead matter, they are irritant 
to the surrounding lung-substance. The bronchial tube which supplies 
the affected lobule, and which in many instances was the starting-point 
of the disease, again becomes pervious, either by softening of the plug 
or by ulceration at a higher point upon its walls, and air is admitted, 
which promotes the putrefactive process and chemical changes of the 
caseous substance. 

The lesion now described is that of pulmonary consumption, a disease 
not infrequent in children of two or three years. There are as yet no 
tubercles, but the presence of softening caseous material in the lungs 
very frequently leads to their development (see Art. Tuberculosis), and 
accordingly, before the case ends, clusters of tubercles may appear in 
the connective tissue and walls of the vessels of the lungs and in other 
organs. 

In the subsequent progress of cheesy pneumonitis, if the patient live 
sufficiently long, more or less expectoration of the offending substance 
occurs, producing a cavity. Around the cavity a vascular pyogenic 
membrane forms, upon which granulations arise. These granulations, 
which produce pus abundantly, and from which small extravasations of 
blood are frequent, are gradually transformed into connective tissue. 
If the dead portion be expectorated, and there be a single small cavity, 
the child may recover, the empty space being finally filled up by the ex- 
tension of the granulations, and the production of a cicatrix, which con- 



SYMPTOMS. 615 

tracts, producing a puckered appearance. Ordinarily, however, there 
are several centres of caseous degeneration, and several cavities result- 
ing, which continue to enlarge by the progressive softening of the cheesy 
matter. Often, also, certain of the cavities intercommunicate. The 
bronchial glands undergo hyperplasia, and certain of them are liable, also, 
to become cheesy. As the disease advances, the suppuration and ex- 
pectoration increase. The fatal result occurs sooner in children than 
in adults, and, therefore, the destructive and inflammatory lesions ob- 
served at autopsies are ordinarily not so far advanced in the former as 
in the latter. Other unfavorable changes may occur in the hepatized 
lung, but cheesy degeneration is the most common and noteworthy. 

The possibility of inflating a lung which presents to the naked 
eye the appearance of pneumonitis, has long been regarded as a reliable 
sign of- the presence or absence of inflammatory consolidation. The 
facts as regards the possibility of insufflation are these : In croupous 
pneumonitis, when it has passed beyond the first stage, insufflation is 
impossible in the lung of the child as well as adult, with the utmost 
force of the breath. We produce emphysema in healthy portions of the 
lungs, while the inflamed area is not encroached upon. 

On the other hand, in catarrhal pneumonitis, which we have seen is 
the common form of pulmonary inflammation in children under the age 
of three years, and in which less distention of the air-cells by inflam- 
matory products occurs, the lung can be inflated, except in protracted 
cases, but when fully inflated the solidified lobules can still be felt be- 
tween the thumb and fingers. In protracted catarrhal pneumonitis, as 
well as in protracted collapse, which, indeed, may and often does become 
a pneumonitis, full inflation is impossible. Central portions still remain 
impervious to air. While, therefore, the possibility or impossibility of 
inflating a lung removed from an adult, and which presents to the naked 
eye the appearance of pneumonic solidification, is a valuable sign as in- 
dicating whether or not the disease be pneumonitis, this test is uncertain 
and unreliable when applied to the pulmonary lesions of children under 
the age of three years. 

Symptoms. — Croupous pneumonitis commonly begins abruptly, or it 
is preceded for a brief period by symptoms of a cold. In the adult, 
the abrupt commencement is ordinarily with a chill. In the child, there 
is often a sensation of chilliness, but a distinct chill is not common. 
Convulsions sometimes occur in place of a chill. Catarrhal pneumoni- 
tis, being ordinarily a secondary disease, begins in a more gradual way, 
its symptoms being preceded by and associated with those of the prim- 
ary affection. 

The symptoms of acute pneumonitis, whether catarrhal or croupous, 
are the following: Anorexia, thirst, restlessness, elevation of tempera- 
ture, acceleration of pulse according to the intensity of the inflammation 
and the feebleness of the patient, flushed face, a countenance expressive 
of suffering, accelerated respiration, with an expiratory moan. These 
symptoms are constant in the acute inflammation unless of the mildest 
form. Those which are important I shall explain more fully. 

The expiratory moan is described by writers as a pathognomonic 
symptom of this disease, or of pleurisy. It is evidently due to the pain 



616 PNEUMONITIS. 

experienced from the movement of the inflamed part. As a rule, the 
expiratory moan indicates either pneumonitis or simple pleuritis ; but 
there are exceptions. It may occur, for example, from indigestible sub- 
stances in the stomach and intestines, giving rise to acute dyspepsia ; 
or from certain forms of abdominal inflammation, which render move- 
ments of the diaphragm painful, as diaphragmatic peritonitis. 

The cough in the first days of pneumonitis is often dry or hacking 
and painful. It afterward, if the case be favorable, becomes looser, and 
is painless. We very seldom observe in the child the bloody sputum 
which characterizes pneumonitis in the adult, since in catarrhal inflam- 
mation there is much less exudation of blood-corpuscles. The sputum, 
which in this form of the disease is the product of secretion and cell- 
proliferation, is at first thin and frothy, but afterward thicker and less 
tenacious from the increased number of cells. There is often, in the 
first period of the inflammation, pretty severe and constant headache, 
the patient complaining of the head, if old enough to speak, before he 
does of the chest. In a severe attack the child at this period lies with 
the eyes shut, apparently in a half-conscious state, fretful if spoken to 
or aroused, so that the physician may be led to suspect the presence 
of cerebral disease. If there be vomiting, accompanied with sudden 
twitching of the muscles, and convulsions — symptoms which sometimes 
occur — the liability to error in diagnosis is greatly increased. Cerebral 
symptoms are more prominent in the commencement of pneumonitis 
than subsequently. As the disease advances they subside, and symp- 
toms referable to the chest become more conspicuous. 

The breathing is, as I have said, accelerated. Thirty or forty respira- 
tions per minute are common, and, in severe cases, the number reaches 
sixty or even eighty. In infants there is greater frequency of respira- 
tion than in children. In those at the breast, if the dyspnoea be urgent, 
nutrition is sometimes seriously interfered with, since in these severe 
cases respiration is performed more through the mouth than nostrils, so 
that if the infant seize the nipple, it is forced to relinquish it in order to 
breathe. Dilatation of the alae nasi, and depression of the inframam- 
mary region, accompany inspiration. The dyspnoea in catarrhal pneu- 
monitis is often due in great part to accompanying bronchitis. 

The temperature in mild cases of pneumonitis is elevated to about 
101° to 103°; in severe cases it may reach 105° 'or even 107°, the 
former being the highest observed by Mr. Squire. In ninety-seven ob- 
servations made by M. Roger, the average temperature was 104° during 
the active period of the inflammation. The face is therefore flushed, 
and the heat of surface pungent, except in weakly children, in whom, 
even in severe and active inflammation, the face is sometimes pallid, and 
the extremities of natural or less than natural temperature. 

The tongue is moist, and covered with a light fur ; the thirst is such 
that nutriment may be given in the form of drinks, when the loss of 
appetite prevents the use of solid food. The bowels are usually consti- 
pated. The secretions, in the first and second stages, are diminished. 
The urine is more deeply colored than in health, and in vigorous patients 
it deposits urates on cooling. The chlorides are also deficient or absent 
from the urine, so long as the inflammation is extending. 



PHYSICAL SIGNS. 617 

In favorable cases, in from seven to ten days the heat and thirst de- 
cline ; the pulse and respiration gradually become less frequent ; the 
cough looser ; the features have a more placid or contented expression ; 
the appetite returns, and the patient is again amused by playthings. 
The improvement is progressive, but gradual. A slight cough is occa- 
sionally observed two or three weeks after convalescence is fully estab- 
lished. 

Death in the acute stage of the inflammation commonly occurs from 
asthenia. The pulse gradually becomes more frequent and feeble, the 
respiration more oppressed, and finally, near the close of life, the face 
and extremities become cool. Occasionally death results from apnoea, 
due in great part to coexisting bronchitis. In exceptional instances it 
occurs from convulsions, followed by coma, especially in the first week. 
In those protracted cases in which the inflammatory products have un- 
dergone cheesy degeneration death occurs from asthenia. 

Such are the symptoms and progress of ordinary acute pneumonitis 
in children. When the inflammation is subacute, as in those forms of 
the disease which result from collapse or hypostasis, the symptoms are 
less pronounced. The respiration in such cases is but moderately accel- 
erated, is attended by little pain, and therefore the expiratory moan is 
often absent. An occasional short, dry cough occurs, with so little in- 
crease of temperature and quickening of the pulse that the pneumonitis 
is often overlooked by the physician, the symptoms being referred to 
bronchitis. Pleuritis seldom occurs in connection w T ith this form of 
pneumonitis, except when a small abscess or gangrene results in an af- 
fected lobule directly under the pleura. A few such cases I have observed. 

Tubercular pneumonitis extends over much or little of the lung accord- 
ing to the amount of tubercles. The symptoms are like those of severe 
primary pneumonitis, superadded to such as pertain to tuberculosis. 
This inflammation, when once established in the consumptive child, 
commonly continues till the close of life. I have sometimes had these 
cases under observation for several consecutive weeks, even months, and 
during the whole time there was not only acceleration of pulse and 
respiration, but the expiratory moan. As regards pneumonitis occur- 
ring in hooping-cough, it is an interesting fact that its symptoms 
modify those of the primary disease, so that, daring the active period 
of the inflammation, the paroxysmal cough diminishes, and a short, 
hacking cough and expiratory moan occur in place. As the inflamma- 
tion abates, the spasmodic cough returns. Pneumonitis occurring in 
measles is more obstinate, protracted, and dangerous than the primary 
form. It usually commences about the period of the decline of the 
eruption, and, in favorable cases, continues two or three weeks. It is 
then a sequel, rather than complication. 

Physical Signs. — The physical signs of pneumonitis in infancy and 
childhood are the same as in the adult, but in a large proportion of 
cases they are less distinct. In a majority of patients under the age 
of three years the crepitant rale is not observed. This is due to the 
small size of the alveoli at this age. I have now and then detected it 
in quite young children, in whom it is a finer rale than in the adult. 
If observed, it is positive proof of the existence of pneumonitis. The 



618 • PNEUMONITIS. 

physical signs, therefore, in the first stage of the inflammation, are often 
obscure in consequence of the absence of the pathognomonic rale. The 
vesicular murmur is somewhat intensified through the chest, and there 
is at this stage slight dulness on percussion over the seat of the inflam- 
mation due to engorgement of the vessels, but it is difficult to appreciate 
this. 

In the second stage, which supervenes more or less rapidly, the 
physical signs are more distinct. Bronchial respiration is in most 
cases detected, higher in pitch than the vesicular murmur, with the 
sound of expiration higher than that of inspiration. The voice of the 
patient is transmitted to the ear applied over the seat of the disease, 
and often a peculiar vibratory sensation is communicated to the hand 
applied over the part, so that it is possible to locate the disease by pal- 
pation alone. In the second stage, and sometimes in the first, coarse 
mucous rales in various parts of the chest are often observed occurring 
from coexisting bronchitis. 

Percussion, in the second stage, elicits a dull sound as compared 
with that produced on the opposite side of the chest. The dulness 
corresponds in extent with the solidification, and with the bronchial 
respiration. 

As the inflammation abates, the dulness on percussion gradually 
diminishes, and the bronchial respiration is succeeded by the subcrepi- 
tant rale. Often, for a considerable period after convalescence is 
established, moist rales are observed in the chest, and sometimes the 
dulness on percussion does not entirely disappear until the health is fully 
restored. 

In catarrhal pneumonitis these signs are commonly less distinct than 
in the croupous form of inflammation. This is due in part to the lim- 
ited extent of the inflammation, in part, in many cases, to its subacute 
character, and in part to the fact that it is in many patients double, so 
that we lose the aid of comparison. When it results from hypostatic 
congestion it is nearly always bilateral. 

Diagnosis. — It will aid in diagnosis to recollect that under the age 
of three years pneumonitis is ordinarily catarrhal, and that it is pre- 
ceded by and associated with bronchitis. Coincident with, and often 
preceding its development for a few days, are the usual symptoms of 
nasal and bronchial catarrh. Defluxion from the nostrils, and other 
symptoms due to "taking cold," help us to diagnosticate catarrhal 
pneumonitis from the essential fevers, with the exception of measles. 
Croupous pneumonitis begins more abruptly, but in this form of inflam- 
mation the greater extent of pulmonary solidification soon gives us clear 
and unmistakable physical signs. The various forms of so-called remit- 
tent fever bear considerable resemblance as regards symptoms to certain 
cases of pneumonic inflammation, but in the latter there are more accel- 
eration of respiration and greater suffering, especially when the child 
is disturbed, than in the former. The physical signs, however, afford 
decisive proof of the nature of the malady, as dulness on percussion, 
bronchial respiration of a higher pitch and harsher than the normal 
vesicular respiratory sound, bronchophony, vocal fremitus, etc. 

Difficulty sometimes attends the diagnosis of broncho-pneumonitis 



PROGNOSIS. 619 

from simple bronchitis. The presence of the expiratory moan, if it be 
pretty constant and marked, affords evidence that the inflammation has 
extended to the lungs, but the physical signs constitute the reliable 
means of exact diagnosis. They should be carefully noted, in order to 
determine if there be some point of solidification. 

Solidification gives rise to dulness on percussion, bronchial respira- 
tion, and bronchophony. These three signs coexisting afford suf- 
ficient proof of pneumonitis, unless there be tubercular consolidation or 
possibly collapse supervening on suffocative bronchitis. The history of 
the case aids in determining whether there be either of these diseases. 
Moreover, collapse occurs later after the attack commences than hepa- 
tization, and does not produce so distinct bronchophony or bronchial 
respiration as is observed in ordinary cases of pneumonitis. 

Pleuritis with effusion may present physical signs which bear con- 
siderable resemblance to those in pneumonia; but in pneumonia, 
except when associated with tubercular disease, the dulness on percus- 
sion is not so great as that from pleuritic effusion. In pleuritic effu- 
sion in a young child the respiratory murmur can often be heard with 
the ear applied over the liquid, but it is indistinct and transmitted 
through the liquid from a distance. The practised ear is able to dis- 
cover the difference between it and the bronchial respiration of pneumo- 
nitis. Yocal fremitus, which is absent in pleuritic effusions, is another 
reliable sign of pneumonitis in children over the age of three or four 
years. In younger children it is indistinct. Occasionally the physical 
signs indicate the coexistence of the pulmonary and pleural inflam- 
mations. 

In catarrhal pneumonitis it is often difficult to determine certainly the 
nature of the disease, since the physical signs, if there be but little ex- 
tent of inflammation, are absent or indistinct. I have often, in post- 
mortem examinations, found so small a part of the lung hepatized that 
it could not possibly have produced any appreciable dulness on percus- 
sion, bronchial respiration, or bronchophony. Such cases often pass for 
simple bronchitis, and, practically, this matters little, since the treatment 
required by the two is not dissimilar. 

Prognosis. — Primary pneumonitis, affecting only one lung, if pro- 
perly treated, in most instances terminates favorably in children, and 
even in infants. If double, it is, as in the adult, much more serious, 
and in a large proportion of cases fatal. Secondary pneumonitis, pneu- 
monitis occurring in measles, hooping-cough, tuberculosis, or resulting 
from hypostatic congestion in the course of some exhausting disease, is, 
on the other hand, more frequently fatal. As death usually occurs from 
asthenia, the younger the child and more feeble the constitution, the 
greater the danger. 

Unfavorable symptoms are a pulse becoming more and more frequent 
and feeble, pallor of countenance, inability of the patient to support the 
head, total loss of appetite, refusal to notice or be amused by play- 
things, absence of tears when crying — a symptom which French writers 
have pointed out — and the appearance of pemphigus on the face or 
elsewhere. 



620 PNEUMONITIS. 

Indications on which a favorable prognosis may be based are mod- 
erate acceleration of pulse, pneumonitis primary and limited to one 
side, ability to support the head or sit erect, being amused by play- 
things, etc. 

Treatment. — The treatment of the two forms of pneumonitis, namely, 
catarrhal and croupous, the former occurring chiefly under the age of 
three years, and being secondary, the latter occurring in most patients 
over that age, requires to be considered separately as much as do their 
symptoms and anatomical characters. 

Catarrhal pneumonitis when developed from and upon a bronchitis, 
as it so often is, requires for the most part the continuance of the reme- 
dies which are appropriate for the primary disease. (See Art. Bron- 
chitis.) But from the fact that it is secondary, and in children of 
tender age, and since the danger as regards the pneumonitis is due to 
asthenia, more actively sustaining measures are demanded than are 
required for uncomplicated bronchitis. When the pneumonitis has 
continued a few days, and often in its commencement, carbonate of am- 
monium and alcoholic stimulants are needed, and the diet from the first 
should be nutritious. An opiate, as the compound tincture of ipecacu- 
anha, should be added to the cough-mixture, if there be restlessness or 
insufficient sleep, and the external treatment recommended for bronchitis 
should be continued. In that form of catarrhal pneumonitis which is 
due to passive congestion or hypostasis, in the causation of which debility 
is an important factor, tonic and stimulating measures are still more 
imperatively required. Frequent change of position is useful in such 
cases. 

In croupous pneumonitis, if seen at the commencement or within a 
few hours of the commencement, an emetic of ipecacuanha may be given, 
as recommended by Trousseau. This acts promptly as a cardiac seda- 
tive, diminishing somewhat the afflux of blood to the lungs, and moderat- 
ing the inflammation. It should not be employed except at the period 
mentioned. 

The abstraction of blood by leeches or otherwise has justly fallen into 
disrepute in the treatment of the inflammations of children, since it is too 
depressing. But while the application of leeches in catarrhal pneumo- 
nitis is very rarely admissible, on account of the tender age of the 
patient and the secondary character of the inflammation, they may be 
useful in robust children with croupous pneumonitis, if applied suffi- 
ciently early, namely, within the first twelve hours. Two leeches are 
sufficient for a child of five years. When solidification of the lung has 
occurred, the time for the abstraction of blood is past. But we have in 
aconite and veratrum viride efficient substitutes for bloodletting, which, 
by their sedative effect on the heart, diminish the exaggerated afflux of 
blood to the inflamed lung, and thus enable us to meet the indication 
of treatment in the first stage of the inflammation. It is important in all 
severe cases to preserve the blood and the strength, for the danger in 
the end is chiefly from asthenia. Aconite as a cardiac sedative in the 
treatment of children is safer than veratrum viride ; it is not necessary 
to watch its effects so carefully. 



TREATMENT. 621 

The following will be found a useful formula for a child of five years 
in the commencement of pneumonia : 

R. — Tine, ipecac, comp. (Squibb's) gtt. xxxij. 

Tinct. rad. aconit. ....... gtt. xvj. 

Syr. bal. tolut. 

Aquse aa^j. 

Dose, one teaspoonful every three hours ; or the aconite may be given alone, 
dropped in sweetened water or syrup of tola. 

If bronchial respiration, bronchophony, and dulness on percussion are 
present, indicating the second stage; in other words^ if it appear from 
the signs that the inflamed lobe or lobes are hepatized, little benefit 
accrues from the further use of aconite or veratrum viride, and harm 
may result. In this stage the above prescription, with the aconite 
omitted, may be continued, or the following may be employed: 

R — Morph. sulphat. . . . . . . gr. j. 

Syr. ipecacuanhse . . . . . . Sss. 

Syr. bal. tolut o"J ss - — ^isce. 

Dose, one teaspoonful every three hours to a child of five years. 

The remarks made in reference to the use of quinia and digitalis for 
bronchitis apply with still more force to their use in both the catarrhal 
and croupous forms of pneumonitis. In secondary pneumonitis and in 
primary occurring in feeble children these agents are in many instances 
preferable to any other medicine for the purpose of reducing the tem- 
perature and pulse, since they produce this result without depression. 
They may be administered in such cases from the first day, and their 
use may obviously be continued longer than would be safe for aconite or 
veratrum viride. 

From some observations recently made (1880— 188 1) in the New York 
Foundling Asylum, it seemed to us probable that quinine, given in one 
or two large doses at the commencement of acute primary pneumonitis, 
as five grains to a child of three years, exerts some controlling effect 
on the inflammation, perhaps even rendering it abortive, and that its 
subsequent use in smaller doses may yet supersede in great part that of 
aconite and veratrum viride. 

When the inflammation begins to abate there is usually progressive im- 
provement. Many now recover w r ith simple mucilaginous drinks or mild 
expectorants useful for the accompanying bronchitis, as syrup of ipecac- 
uanha or squills in small doses. Others require more sustaining meas- 
ures, and for such carbonate of ammonium is preferable with, perhaps, 
quinia. In severe pneumonitis it is of the utmost importance to sustain 
the vital powers, even from the commencement of the inflammation. 
There can be no doubt that the great error in the therapeutic manage- 
ment of children with this malady has been the employment of medicines 
which reduce the strength when gentler measures or those of a sustain- 
ing nature were needed. Alcoholic stimulants are required sooner or 
later in most cases, at an early period in feeble children and in secondary 
forms of the inflammation. Infants may take three or four drops of 
Bourbon whiskey or brandy for each month of their age every two or 
three hours. The diet should be nutritious, consisting of milk, animal 
broths, and the like, unless during the first three or four days in robust 
children. 



622 PLEURITIS. 

The bowels should be kept open, as an important part of the treat- 
ment of croupous pneumonitis in its first stages. A small dose of castor 
oil, Rochelle salts, or citrate of magnesium should be given if there be 
any tendency to constipation, and repeated from time to time if re- 
quired. A saline aperient by its derivative and refrigerant effect in 
some cases obviates the necessity of employing cardiac sedatives. A 
laxative enema is preferable for a feeble child, and in most cases of sec- 
ondary pneumonitis. 

Local treatment is required in all cases ; counter-irritation should be 
produced as soon as possible over the inflamed lobe, by mustard, iodine, 
or some stimulating liniment, and, except at the time of this application, 
the chest should be constantly covered with an emollient poultice, or 
w T ith a cloth wrung out of warm water and covered with oil-silk. I 
prefer, however, the constant application, under the oil-silk, of the fol- 
lowing poultice, made large, but as thin as the pasteboard cover of a 
book, and therefore light : 

R. — Pulv. sinapis ^ss. 

Pulv. semin. lini ...... ^viij. — Misce. 

Vesication, in my opinion, very rarely expedites the cure or benefits 
the patient. The ordinary fly-blister should never be employed ; and 
if it be thought best to vesicate, cantharidal collodion should be pre- 
scribed for this purpose. A safe, almost painless, and at the same time 
efficient, mode of applying this, is in spots as large as a ten-cent piece, 
half a dozen, more or fewer according to the extent of the inflammation, 
the skin of course remaining sound between them. This mode of ap- 
plication obviates the danger of producing a troublesome sore, which 
sometimes occurs in children from the ordinary mode of vesication. 

In cheesy pneumonitis, which is always accompanied by anaemia, 
and great reduction of the vital pow r ers, carbonate of ammonium with 
citrate of iron and ammonium equal parts, or cod-liver oil administered 
three times daily with two drops or more of syrup of iodide of iron, will 
be found useful, as is also quinine with iron. Patients require the 
most nutritious diet and alcoholic stimulants. In the local treatment of 
this form of inflammation vesication, even so mild as that by cantharidal 
collodion, should be avoided. 



CHAPTEE VII. 

PLEURITIS. 1 

The term pleuritis or pleurisy is employed, in this chapter, to 
designate inflammation of the pleura, when not produced by extension 
of the inflammatory process from the lung, or by the irritation of 
tubercles upon or under the pleura. Catarrhal pneumonia, common in 

1 Prom the New York Obstetric Journal, 1880-1881. 



FREQUENCY. 623 

infancy; croupous pneumonia, common in childhood; pulmonary tuber- 
culosis, not rare in both periods in wasted and cachectic children, are 
ordinarily accompanied by pleurisy, arising consecutively to the lung 
disease, and limited nearly to the portion of the pleura -which covers 
the affected lobes or lobules. But since in these cases the pleuritis is 
subordinate to and dependent on the graver diseases, and is compara- 
tively unimportant, it does not require separate consideration. It is 
properly treated of in our books in connection with and as a part of 
those diseases. All other cases of pleuritic inflammation, although pre- 
senting wide differences in form and clinical history, are embraced under 
the general term pleuritis. 

Pleuritis : its frequency. — Pleuritis was formerly supposed to be 
rare in young children. Even M. Barrier, of Lyons, the author of a cred- 
itable treatise on diseases of children, wrote as late as 1860 : " Ainsi done, 
en generalisant les faits de Yallieux et les notres, nous pouvons dire : 
que la pleurisie, depuis la naissance jusqu'a l'age de six ans environs, ne 
constitue presque jamais une affection simple, unique, et independante 
de la pneumonic " But greater precision in the examination of cases, 
more accurate means of diagnosis, more knowledge of the nature of dis- 
eases, and more frequent autopsies have enabled the profession to cor- 
rect this, as well as many other errors ; and it is • now known that 
primary pleurisy is not infrequent in young children, even in infants. 
In asylums and hospitals for children, in which institutions the nature 
of diseases is more accurately ascertained than in private practice — for 
autopsies are made in the fatal cases — the frequency of pleurisy in its 
various forms: latent, semi-fibrinous, and purulent, is surprising to 
those whose knowledge of the disease has been acquired only through 
private practice. Thus, in the New York Foundling Asylum, in the 
seven months from April 1 to November 1, 1879, while there were 
35 cases of bronchitis, 21 of pneumonia, and 3 of tuberculosis, there 
were 11 clearly ascertained cases of pleurisy. There can be no doubt 
that many cases of this malady in young children are mistaken by good 
practitioners for other diseases, especially for pneumonia, or, if the 
pleurisy be to a certain extent latent, for remittent or malarial fever, 
or fever due to intestinal irritation. I have records of several cases 
occurring in family and hospital or asylum practice, in which children 
perished with a wrong diagnosis, or without diagnosis, when the post- 
mortem examination revealed pleurisy, sometimes of long standing. 
Thus in one case of fatal empyema, commencing at the age of six 
months, and continuing several months, chronic pneumonia had been 
diagnosticated by physicians known to be thorough in their examina- 
tions, and usually accurate. In another case, which proved fatal at 
about the age of one year, the child, who lived in a malarial locality, 
had been for weeks under treatment for supposed malarial disease; 
but in this case diagnosis was easy, for at my first visit, which was 
when the child was dying, there was decided dulness on percussion over 
the right side of the chest. In this case, the right lung was adherent 
to the ribs anteriorly and laterally, while posteriorly it was separated 
by pus, which crowded forward the organ, so that its posterior surface 
was concave. 



(324 



P L E U R IT I S 



In wards of institutions and in the crowded quarters of the poor, 
pleurisy appears to be more frequent than in families in comfortable 
circumstances. Its frequency varies, also, in different years, according 
to the presence and prevalence of its causes. Thus, during epidemics 
of scarlet fever, it is more common than at other times. 

During several weeks immediately preceding May, 1874, when there 
was no unusual prevalence of the causes or conditions which give rise 
to pleurisy, I noted carefully the character of the sickness in 404 con- 
secutive cases, under the age of twelve years, in private practice, and 
of these, two had primary pleurisy, or one-half per cent. This is prob- 
ably about the usual proportion of pleurisies in children in family prac- 
tice, except when scarlet fever is prevalent. 

I have preserved the records of 56 cases of pleurisy in children 
under the ages of twelve years, most of them occurring in the institu- 
tions which I am attending, or have attended as physician, and the 
remainder in private practice. The statistics of these cases, embraced 
in the following table, are interesting, as showing the frequency of 
pleurisy, and pleurisy of the suppurative form, in young children. The 
large number of empyemas seen in the table does not, however, indicate 
the true proportion of suppurative to sero-fibrinous pleurisies, since 
protracted and stubborn cases, which are largely empyemas, are more 
frequently brought to institutions for treatment than are those of a 
milder and more manageable type. Thus, in the class of children's 
diseases in the Bureau for the Belief of the Outdoor Poor, a large per- 
centage of the cases are empyemas which have resisted treatment else- 
where. Besides, pleurisy with little exudation is sometimes latent or 
so mild that it is overlooked or not diagnosticated, even by physicians 
who are thorough and careful in their examinations, and I do not doubt 
that such cases have occurred in the institutions and in my private 
practice during the time in which my statistics were collected. 







Age. 49 Cases. 






Under 2 Mos. 


From 2 to 6 Mos. 


From 6 to 12 
Mos. 


From 1 Tr. to 
3 Yrs. 


From 3 Yrs. to 
6 Yrs. 


Over 6 Yrs. 


3; all empy- 


15 ; nine at 


2; both em- 


13 ; eight 


10 ; seven 


6 ; five right, 


emas ; one 


least em- 


pyemas ; 


right, five 


right, 


one left, 


double. 


pyemas ,' 


one ri^ht, 


left. 


three left. 


one em- 




seven on 


the other 


Exudation 


Exudation 


pyema. 




right 


left. 


in some 


in some 






side, four 




sero- 


sero- 






on left 




fibrinous ; 


fibrinous ; 






side, four 




in others 


in others 






double. 




purulent. 


purulent. 





Causes. — The common cause of primary pleuritis is the same as that 
of other idiopathic inflammations, namely, " taking cold." It is, there- 
fore, most common in times of changeable temperature. Cachexia is 
an acknowledged predisposing cause, so that children whose blood is 
impoverished, whether from previous disease or from anti-hygienic in- 
fluences, are more liable to this inflammation than those who possess a 
sound and vigorous constitution. From the operations of these two 



causes. 625 

causes a larger proportion of cases occur among the children of the city 
poor than among those who are well nourished and who live in com- 
fortable circumstances, since the cachectic and ill-cared for are not only 
more exposed, but are less able to resist noxious agencies. 

Pleurisy is not rare in newborn infants, and its cause, when thus 
occurring, is not always apparent. It may sometimes be heedless 
exposurs to cold or to currents of air by the nurse, but the common 
cause at this age is believed to be the absorption of septic matter. 

Billard, whose observations were made among foundlings in the Hos- 
pice des Enfants Trouves, says : " Pleurisy is more common among 
young infants than is generally supposed; it often appears without the 
lungs participating in the inflammation. I have seen several infants 
die immediately after birth from this affection." He relates two cases 
of double idiopathic pleuritis ending fatally at the ages of two and ten 
days (Diseases of Infants, page 419). Mignot, whose observations were 
made in the same institution, also records ten pleurisies, five of which 
were idiopathic, in 119 dissections of newborn infants (Maladies pen- 
dant le Premier Age). 

Cases like the following are not infrequent: 

In 1867, I made the post-mortem examination of a foundling who died 
in the New York Infant Asylum, at the age of about one month. On 
each side of the thorax, the pleura, costal and pulmonary, was uniformly 
injected, and a small amount of pus, not more than one drachm, was 
found in one pleural cavity, and a still less quantity of pus in the other, 
with little or no sero-fibrinous exudation. There was also pus at the root 
of each lung, lying not entirely ujdou the free surface of the pleura, but 
partly underneath it. 

The fact of a double pleurisy without disease of the lungs, which 
might produce it, indicated a constitutional cause. Its system had 
probably become infected by the absorption of septic matter from the 
umbilical vessels. 

One of the eruptive fevers, scarlatina, not infrequently produces pleu- 
ritis, occurring as a complication or sequel. This result seems to be 
sometimes due to the altered state of the blood, resulting from the pres- 
ence of the scarlatinous virus. In other instances it is probably the 
result of retained urea, consequent on scarlatinous nephritis, for 
pleuritis is a common complication of Bright's disease, due, it is sup- 
posed, to the irritating property of urea, which is excreted upon the 
pleural surface. Pleuritis, in young children, is sometimes also caused 
by the discharge into the pleural cavity of some morbid product, as pus, 
softened tubercle, or decomposed lung-tissue, which, from its highly ir- 
ritating effect, causes intense and general inflammation of the pleura. 
I have observed several such cases. 

Thus, in November, 1866, an infant of three and a half months died of 
pleurisy, occurring upon the left side. The left lung was firmly bound 
down by adhesions, so as to be reduced to about one-sixth its normal 
size. On attempting inflation of this organ, when it was removed from 
the body, air escaped from a small opening in the middle of the upper 

40 



626 PLEURITIS. 

lobe, and around this opening the lung-substance was of a dark reddish 
color, softened and disintegrated. It seemed probable from the appear- 
ance that there had been hypostatic congestion, or perhaps pneumonia, in 
the posterior part of the lung, and that the loss of vitality and softening 
had occurred from the sluggish or suspended circulation in the part, and 
that the fatal pleurisy had resulted from a little of this decomposed tissue 
entering the pleural cavity. 

A case having apparently a similar origin occurred in the New York 
Foundling Asylum in October, 1879. 

An infant, aged five months and a half, became suddenly and severely 
sick with pleurisy on the right side, and died in five days. On opening 
the pleural cavity, air escaped. The record of the examination states : 
" In about the middle of the posterior surface of the lower lobe was an 
opening which admitted the tip of the little finger to the depth of one- 
fourth to one-third inch. The lung-tissue seemed to be disorganized, and 
of pultaceous consistence around the cavity. Through this cavity, which 
communicated with a bronchial tube, the air had escaped, which was 
noticed on opening the chest." 

Occasionally we meet cases, especially in foundling asylums, in which 
the cause is different from the foregoing, but in some respects similar. 
An indolent pneumonitis occurs over a circumscribed area in the pos- 
terior part of the lung, either from hypostasis or exposure to cold. 
Minute abscesses form in the inflamed parenchyma, not larger than 
pins' heads or small shot. Perhaps they are located in bronchioles, and 
are produced by the accumulation of muco-pus which collects in these 
tubes, and is not expectorated on account of the low vitality and feeble 
functional activity of the tissues concerned. These abscesses approach- 
ing the pleural surface produce a circumscribed pleuritis of small extent ; 
and finally one, probably in some sudden movement of the lungs, as in 
crying or coughing, breaks into the pleural cavity, causing general puru- 
lent inflammation. The following w T as such a case : 

In May, 1859, a male infant, aged two months, was admitted into the 
Nursery and Child's Hospital. He was delicate, and had what was diag- 
nosticated a mild bronchial catarrh ; but by wet-nursing his general con- 
dition gradually improved. In July, however, he had repeated attacks 
of diarrhoea, and progressively lost flesh and strength. On August 3d his 
respiration became suddenly accelerated and painful, and death occurred 
from dyspnoea and exhaustion. No cough or other symptoms referable 
to the respiratory apparatus had been observed previously to the day of 
death. 

At the autopsy the intestines were found to present the usual lesions of 
intestinal catarrh of the summer season. The right lung was compressed 
by a sero-fibrinous exudation, though, from the small size of the pleural 
cavity, the quantity of exuded liquid was not more than two ounces. 
Nearly the entire right pleura, visceral and parietal, was covered with 
fibrin of a creamy appearance, and there were loose flocculi in depending 
portions of the cavity. This lung could be inflated, except a little of the 
lower lobe, which was hepatized. The left lung also occupied a very small 
space, being partially collapsed. It could be readily inflated, when it ap- 



causes. 627 

peared normal, except a small portion in the posterior aspect of the lower 
lobe, which was partially covered with lymph, and was found to contain 
two abscesses, one closed and the other opening externally on the surface 
of the lung, and connecting internally with the bronchial tube. On 
attempting inflation, air passed directly through this opening. The closed 
abscess contained from one-third to one-half a drachm of pus and disin- 
tegrated lung-tissue, as shown by the microscope. 

Another case showing a similar cause of pleurisy occurred in a female 
infant of about four months, in the same institution, in November, 
1869. 

She was admitted in October, somewhat reduced from diarrhoea, but 
her health improved partially, though she remained feeble, and the 
records state that she was much troubled with meteorism and occasional 
pain. On November 2d, she was suddenly seized with great dyspnoea, 
and died in about fifteen minutes. No cough had been noticed or other 
symptom referable to the chest, but there can be little doubt that the 
occasional symptoms of pain, referred to in the notes, were due to the 
pleurisy. The body was much emaciated, and depending portions showed 
hypostatic congestion ; right lung adherent to diaphragm and to a con- 
siderable part of the costal pleura by fibrinous exudation ; this lung was 
somewhat compressed and non-crepitant ; its upper lobe floated in water, 
while its middle and lower lobes sank, and could be only partially in- 
flated ; this portion of the lung contained a few small superficial abscesses, 
each holding scarcely more than one drop of pus; two of these were 
empty, and air passed through them on attempting inflation. They 
probably one or both opened into the pleural cavity during life, but pos- 
sibly they were opened in separating the adhesions which united the two 
pleural surfaces at this point ; the pleural cavity contained from two to 
three ounces of liquid, consisting mainly of pus and fibrinous shreds. 

A similar case occurred in the New York Foundling Asylum, in 
October, 1879. 

The patient, aged four months, began to be sick October 11th, having 
the characteristic symptoms, and died October 15th. The right pleural 
cavity contained about ^iij of sero-purulent liquid, pressing the lung for- 
ward and toward the median line. In the posterior surface of the right 
lower lobe, near its base and immediately under the pleura, were three or 
four small abscesses, each not larger than a small drop of pus, and two 
or perhaps three of these had ruptured, so that air escaped from them on 
attempting inflation, while one was closed, the pus in it being visible under 
the pleura. 

This cause of pleurisy, namely, the bursting of a minute abscess in 
the lung, and that in which a portion of the lung loses its vitality, dis- 
integrates, and enters the pleural cavity, are probably rare, except in 
the first months of infancy in wasted and ill-conditioned infants, in 
families of the city poor and in the asylums. 

A peri-pharyngeal abscess, descending along the oesophagus, has been 
known to cause fatal pleuritis by bursting into the pleural cavity, and 
pus from carious vertebrse has produced the same result. In January, 



&2S PLEURITIS. 

1864, I presented to the New York Pathological Society the lungs of 
an infant whose history was as follows : 

B,, aged nine months, of strumous parentage, and whose only sister had 
Buffered severely from strumous ophthalmia and periostitis, was taken sick 
about December 19, I860, with febrile movement, attended by restless- 
ness, but apparently without any serious indisposition. On the 22d. the 
mother called my attention to a prominence just below the right clavicle, 
which proved to be an abscess, and a poultice was applied over it. On the 
24th, the prominence suddenly subsided, and immediately the symptoms 
were greatly aggravated. The pulse rose to 160 per minute, the respira- 
tion from 60 to 80, and expiration was accompanied by a moan, indi- 
cating acute pleuritic or pulmonary inflammation, Within forty-eight 
hours after the disappearance of the swelling, and the exacerbation of 
symptoms, dulness on percussion over the right side of the chest Mas 
observed, and this increased till it was complete from the clavicle to the 
base of the thorax. The acceleration of pulse and respiration continued, 
the patient grew more and more feeble, and death occurred December 
31st, 

On dissecting away the integument from the right side of the chest, an 
abscess was opened, containing nearly one ounce of pus, located at the 
point where the tumor had been observed. At the base of this abscess, 
between two of the ribs, was a small, round opening, not much larger than 
a knitting-needle, leading directly into the cavity of the chest, so that 
on depressing the ribs liquid flowed back from the pleural cavity. On 
removing the sternum the liquid was found to be sero-fibrinous, with con- 
siderable pus in depending portions of the cavity. 

I have met one other, apparently almost identical case, occurring in 
an infant of seven months. 

Pleurisy in the adult is sometimes the result of violence. The most 
notable and unequivocal cases, having this origin, are those in which the 
ribs are fractured. It rarely happens that we can attribute the pleurisy 
of children to this cause. I can recollect only one case in which the 
inflammation seemed to be due to violence. 

In September, 1867, an infant of twenty-two months, in the Almshouse 
on Blackwell's Island, having had a cough for half a year, and being some- 
what reduced, fell from bed, striking against the left side of the thorax. 
Severe pleuritic symptoms supervened, and the child died of empyema 
in three and a half weeks. More than a pint of pus was found in the 
left pleural cavity, pressing the heart beyond the median line, and the 
diaphragm downward, so that it was convex toward the abdomen. The 
bronchial glands were hyperplastic and slightly cheesy, and a caseous 
nodule lay in the anterior surface of the right lung, which seemed other- 
wise healthy. The left lung bound down by adhesions could be partially 
inflated. Whether or not it contained small tubercles is not stated in the 
records. 

The occurrence of the injury just before the commencement of the 
pleurisy may indeed have been a coincidence, but the mother constantly 
believed that the fall caused the inflammation, and there was no other 
assignable cause. 

It is probable, from the history of this case and the lesions, that the 



ANATOMICAL CHARACTERS. 629 

cheesy degenerations antedated the fall, and that the pleura was in an 
abnormal state and prone to inflammation when the injury was received. 

The etiology of pleurisy in children differs, therefore, from that in 
adults. Certain causes are the same ; but others, as scarlet fever, and 
irritating products generated in the walls of the chest and bursting into 
the pleural cavity, are not rare in infancy and childhood, while they 
seldom occur in adults. 

Anatomical Characters. — In the commencement of pleuritis, the 
subpleural bloodvessels, lying in the connective tissue, and the capilla- 
ries of the pleura are engorged with blood, producing vascular points 
and arborescence, seen through a magnifying-glass of low power. 
Frequently, in children as in adults, minute extravasations of blood, 
resulting from extreme congestion, occur under the endothelial layer, 
perhaps scarcely perceived by the naked eye, but readily seen under the 
glass. Immediately exudation of liquid, holding numerous cells, begins 
in the connective tissue which surrounds the capillaries, the pleura 
becomes dry and lustreless, while the production and exfoliation of its 
endothelial cells are greatly increased. These no longer present their 
normal appearance, but are swollen and granular, in consequence of the 
inflammation. 

Immediately after these parenchymatous changes occur, serum, fibrin- 
ogenic substance, and leucocytes begin to exude upon the free surface of 
the pleura. The term fibrinogenic substance, instead of fibrin, is em- 
ployed, because it is now believed that fibrin itself is not exuded, but a 
substance which becomes fibrin, through the presence and action of cer- 
tain agents with which it comes in contact, among which may be men- 
tioned air, red blood-corpuscles, and even serum, from which fibrin has 
been precipitated (Virchow, Cornil, Ranvier, and others). 

In the exuded liquid, even if it have the appearance to the naked eye 
of ordinary serum, the microscope always reveals the presence of pus- 
cells or leucocytes, and red blood-cells, however small their quantity 
may be. The minute rootlets of the lymphatic system, which are inter- 
spaces or lacunae in the subpleural connective tissue, and which, here 
and there, open by stomata upon the pleural surface, are clogged by in- 
flammatory products, and their walls swollen at an early stage (E. 
"Wagner and others). In these lymphatic channels, both pus-cells and 
coagulated fibrin are seen by the microscope. That pneumonitis, 
whether catarrhal or croupous, seldom occurs in superficial parts of the 
lungs without causing inflammation of that portion of the pleura which 
covers the affected lobules is universally known : but the reverse is also 
true, that pleurisy seldom occurs without causing inflammation of the 
alveoli which are adjacent to the inflamed membrane. The pneumonitis 
thus caused is so superficial that it is very liable to be overlooked at the 
post-mortem examination, in the presence of the graver lesions of the 
pleura; but a knowledge of its occurrence is important in diagnosis, 
for, though it may have no greater depth than a line, it is sufficient to 
produce crepitant rales, like those in ordinary pneumonitis. Therefore, 
if we hear these rales, we may mistake the disease for pulmonary in- 
flammation and overlook the pleuritis — an error not unusual in the 
treatment of children. Trousseau, who surpassed most of his contempo- 



030 PLEURITIS. 

raries as a clinical observer, wrote : " This sound, which is met with in 
the great majority of cases of pleurisy, is in fact a crepitant rale, and I 
have called it a crepitant rale of pleurisy. My interpretation is very 
simple. Just as we never have erysipelas without engorgement of the 
cellular tissue, there cannot be erysipelas of the pleura or pleurisy with- 
out an irritative engorgement of the subpleural cellular tissue or of the 
peripheric pulmonary parenchyma. This fluxion naturally carries with 
it into the pulmonary vesicles a serous exudation. . . . We also meet 
with a fine subcrepitant rale, which is very often heard quite at the 
beginning of pleurisy, and which likewise nearly always continues for 
some weeks." More recent observers and writers fully agree with the 
statement of Trousseau, except that what he designates irritative en- 
gorgement the microscope shows to be a true inflammation of the pul- 
monary alveoli. 

There are four constituents of every pleuritic exudation, namely, 
serum, fibrin, red blood-corpuscles, and leucocytes or pus-cells, which last 
are identical, in appearance, with the white blood-corpuscles and the 
lymph-corpuscles, and the origin of which has been investigated by 
many microscopists. It is convenient to classify cases of pleuritis 
according to the quantity and relative proportion of these constituents 
as follows : 1st. The plastic, sometimes designated dry or adhesive. 
2d. The sero-fibrinous. 3d. The purulent. 4th. The hemorrhagic. 
In cases which pertain to the first group, the inflammation is chiefly 
parenchymatous, either no exudation occurring upon the free surface of 
the pleura, or if any, whether fibrin, pus, or serum, it is so slight that 
it possesses no clinical importance. The essential anatomical changes 
in this form of pleuritis, as regards the pleural surface, are rapid pro- 
liferation, retrogressive change, or decay and exfoliation of the endothe- 
lial cells, and the sprouting out of granulations which develop into 
connective tissue. In plastic pleuritis, there is no compression of the 
lungs, and the pleural surfaces are separated from each other only by 
the granulations which soon unite with those of the opposite surface. 
This form of pleuritis is not infrequently latent in children, for at the 
autopsies of those who have died of various diseases we often observe 
bands of connective tissue, uniting the opposite pleural surfaces, when 
the parents or nurses cannot recall to mind any sickness or symptoms, 
such as pleuritis commonly causes. It is certain, also, that plastic 
pleuritis is often overlooked, when not latent; the fever and other 
symptoms being attributed to causes quite distinct from the true one. 
The symptoms and physical signs are obviously less pronounced in this 
than in other forms of pleuritis. 

2d. Sero-fibrinous Pleuritis. — This is the most frequent of all. 
It is the pleuritis which commonly results from catching cold. The 
serum exudes from the capillaries of the inflamed pleura in very variable 
quantity in different cases, and the pleural surface is soon covered with 
a fibrinous layer. This may be a mere film, or it may attain the thick- 
ness of half an inch or more. It is usually at first slightly attached, 
but afterward, from being blended with the granulations, it may be 
firmly adherent. In some cases it is quite compact, while in others it 
has a loose areolar texture, containing in its interstices serum and pus- 



PURULENT PLEURITIS. 631 

cells. The fibrin is for the most part deposited on the pleura, but shreds 
and flakes of it also float in the serum. In the serum, as well as en- 
tangled in the fibrin, we find not only red blood-cells and leucocytes, 
but endothelial cells thrown off from the pleura which, as well as those 
still adherent, are almost always in process of degeneration and decay. 

If a perpendicular section be made through the pleura, in this as ->\ell 
as in the other forms of pleuritis, many newly formed cells, the lymph- 
corpuscles, are observed in the meshes of the subpleural connective 
tissue, and, as we examine the section nearer to the surface of the 
pleura, these cells are seen to be aggregated in masses, and held together 
by a structureless, homogeneous matrix. The lymph-corpuscles appear 
to be the active agents in the formation of granulations. They are ob- 
served in various stages of transformation, from the round to the spindle- 
shaped. The prolongations of the spindle-shaped cells unite with each 
other, so as to form the connective tissue, capillaries, and other elements 
of the granulating surface. That the endothelial cells take no part in 
the production of the new tissue is inferred from the fact that most of 
them present the appearance of retrogressive change and decay. The 
granulations, as they sprout out from the pleura, become intimately 
blended with the fibrinous exudation, and when the effused liquid is ab- 
sorbed, they unite with those of the opposite pleural surface, forming 
an organic union, by bloodvessels and nerves, between the lung and 
parietes, the lung and pericardium, or different lobes of the same lung, 
as the case may be. They pass, in two or three weeks, from embryonic 
to perfect tissue, vessels and nerves grow in them, and they possess, 
henceforth, all the properties of living tissues ; they are able to absorb ; 
they are liable to inflammation and hemorrhage, and may, in fine, par- 
ticipate in all the alterations of the organism of which they are a part. 
(Jaccoud.) 

3d. Purulent Pleuritis. — Although, as stated above, pus-cells are 
always present in the pleuritic exudation, we designate the disease pur- 
ulent or empyema when the cells are so numerous as to render the 
liquid turbid. If there be cloudiness, appreciable to the naked eye, 
and due to the pus-cells, the case is regarded as one of this form of 
pleuritis. Purulent pleuritis is, at first, in a large proportion of cases, 
sero-fibrinous, becoming purulent after some days or weeks — a fact 
readily ascertained by the use of the hypodermic syringe at different 
periods. In other instances, the pleuritis is purulent from the first. 
Pleuritis is, in family and in hospital practice, more frequently purulent 
in children than in adults, and in ill-conditioned children than in those 
who are robust. It is, therefore, apt to be purulent in one who has had 
an exhausting disease, as scarlet fever, and in the cachectic children, 
who reside in or are brought to institutions for treatment. Thus, in the 
New York Foundling Asylum, in 1879, an infant, aged two months 
and three days, became feverish, and had the expiratory moan and 
hurried respiration characteristic of pleuritis. On the fourth day, Dr. 
Reynolds, who was in attendance, inserted the hypodermic syringe and 
filled it with thin pus. This was, apparently, a case of primary idio- 
pathic empyema. Pleuritis is purulent when it is produced by the 



032 PLEURITIS. 

entrance of some irritating substance into the pleural cavity, as pus or 
decomposed lung-tissue. 

The production of pus in the pleural cavity is often surprisingly rapid, 
for, when many ounces have been removed by the aspirator, nearly the 
original quantity is sometimes restored within two or three days. As 
Fraentzel says, it does not seem possible that so many pus-cells, which 
must surpass in number the aggregate of the white blood-corpuscles, 
could wander from the bloodvessels in so short a time, so that we must 
look for some other source of the immense production of leucocytes, in 
addition to that discovered by Cohnheim. A large part of the pus- 
cells is, in all probability, produced by rapid segmentation of the lymph- 
corpuscles. In two cases of purulent pleuritis, both infants, I found 
pus underlying the pleura near the hilus, without apparently any loss 
of integrity in the pleura, in such quantity that it was immediately re- 
cognized by the naked eye. Pus under the pleura, as well as within the 
pleural cavity, was apparently due to unusual violence in the inflammar 
tion, and rapid production of leucocytes. 

Hemorrhagic Pleuritis. — This is not common. I recall but one 
case in a child, in whom the pleuritis occurred as a sequel of scarlet 
fever. The fluid several times removed by the aspirator had a deep 
reddish-brown color. I was apprehensive that the point of the aspirator, 
by wounding the granulations, had caused the hemorrhage which stained 
the pus removed at each subsequent operation. But, with the care ex- 
ercised, and the great amount of blood-stained exudation, it seems almost 
certain that this was not the true explanation, and that it was a genuine 
case of hemorrhagic pleuritis. 

Hemorrhagic exudation in the pleuritis of children is sometimes due 
to purpura hemorrhagica, being like the other hemorrhages a symptom 
of the general disease. In other cases it signalizes the commencement 
of a new inflammation in the vascular granulations of a previous pleu- 
ritis. Occurring under such circumstances, it is due to the increased 
fluxion in the numerous delicate capillaries of the granulations. Pleu- 
ritis due to cancerous or tubercular formations in or upon the pleura is 
sometimes also hemorrhagic. Jaccoud says: " A sero-fibrinous or 
purulent exudation may be red by the transudation of hematin, without 
true hemorrhage . . . ; the red exudations which have been ob- 
served in scorbutus and marsh cachexia are really due to these pseudo- 
hemorrhages," In those cases in which there is true hemorrhage, it is 
still uncertain whether rupture of the capillaries or a transudation ordi- 
narily occurs, or whether the blood-cells may not escape in both modes. 

A liquid pleuritic exudation, whether sero-fibrinous or purulent, 
obviously produces an important mechanical effect from its location. 
In young children, especially those enfeebled by sickness, the expan- 
sive power of the lung is slight, so that it readily yields to pressure 
applied to its surface, and becomes more and more compressed as the 
liquid accumulates. Except when retained by adhesions, the lung is 
pressed toward the mediastinum, and at the same time carried forward 
and upward. Patients with pleuritis usually lie on the back and affected 
side, so that gravitation determines to a considerable extent in what 
part of the pleural cavity the liquid will collect. In the considerable 



HEMORRHAGIC PLEURITIS. 633 

number of post-mortem examinations which I have witnessed of chil- 
dren who perished from pleuritis, chiefly empyema, the lung was usually 
attached anteriorly to the thorax from the mediastinum outward, as far 
as the costo-chondral articulations, or further, except in the lower part 
of the cavity, where there were no adhesions, or adhesions only near 
the mediastinum. There were also attachments along the mediastinum, 
and attachments more or less firm on all sides, anteriorly, laterally, and 
posteriorly in the upper part of the pleural cavity, toward which the 
lung was compressed. Many variations occur, depending on the amount 
of liquid and the extent of the adhesions ; but judging from autopsies 
which I have seen, I would say that, in the average, in cases so severe 
that the question of operative interference arises, if we draw a line from 
the axilla downward and forward to the epigastrium, the lung is adhe- 
rent to the thorax over the space anterior and internal to this line, 
while external and posterior to it the liquid separates the lung from 
the ribs. This fact is important, as indicating the proper point for 
puncturing the chest, namely, below the lower angle of the scapula, 
and between the eighth and ninth ribs. One reason why the earlier 
performers of thoracentesis were so unsuccessful was that they selected 
the anterior wall of the chest as the point of operation. Nowadays, 
however, no one would be justified in performing thoracentesis unless 
he first employed the hypodermic syringe and removed fluid at the 
point which he selects for the puncture. The statistics of Mohr, relat- 
ing to lung displacement in empyema, chiefly statistics of adult cases, 
are somewhat different from my general recollection of cases occurring 
in infancy and childhood as stated above. In 23 cases he found the 
lung free from adhesions, and compressed against the vertebral column 
and the mediastinum ; in 13 cases the organ was compressed from 
below upward ; in 1 from above downward ; in 4 from within out- 
ward; in 4 from behind forward, and in 4 from before backward. 
These variations depend on the adhesions which the lung happens to 
contract. Perhaps a point a little external to the perpendicular, pass- 
ing through the angle of the scapula, is preferable for puncture, as I 
have known the lung to be adherent to the posterior wall of the chest 
near the mediastinum, when the portion further removed, say two inches 
from the median line, was separated by interposed liquid. 

Sometimes the liquid is collected in multilocular cavities formed by 
the connective tissue, and these frequently intercommunicate. Excep- 
tionally in children, as in the adult cases observed by Mohr, when there 
has been a large and rapid liquid exudation, or when the disease has 
been violent and of short duration, adhesions do not occur. 

On account of the great difference in the size of the pleural cavity at 
different ages during infancy and childhood, the amount of liquid which 
produces that degree of compression of the lung which materially im- 
pairs its function, varies greatly. At the age of four months, three 
ounces produce complete collapse of lung, so that it resembles a fleshy 
mass (carnification). The largest amount of liquid relatively to the size 
of the chest, in any of the cases which I have observed, was about one 
and one-half pints, in the left pleural cavity in an infant that died at 
the age of twenty-two months, in September, 1867. The heart lay 



684 PLEURITIS. 

chiefly to the right of the median line, and the diaphragm was convex 
toward the abdominal cavity. The case occurred in the Almshouse on 
Blackwell's Island, and might in all probability have been relieved 
had attention been directed to it sufficiently early. 

Liquid in the left pleural cavity, when considerable, presses the heart 
toward the mediastinum, so that the apex beat, instead of being a little 
internal to the linea mammalis, approaches the sternum. As the heart 
is carried to the right, the beat is felt under the lower end of the ster- 
num, and with still greater increase in the effusion, the pulsation is 
detected by the finger, to the right of the sternum. If the exudation 
be on the right side, the displacement of the heart toward the left is, for 
obvious reasons, less than the displacement toward the right, in pleu- 
ritis of the left side. Much external pressure upon the heart embar- 
rasses its movements, and prevents proper filling of its cavities, while 
the action of the organ is accelerated so as to compensate. Therefore, 
the pulse is quick and feeble. 

In one instance in my practice, the lower extremities, and the portion 
of the trunk below the thorax, became (Edematous, from compression of 
the ascending vena cava, and writers allude to cases in which other 
vessels and ducts, as the thoracic, were compressed, so as seriously to 
embarrass their functions. The patient with the oedema was a boy of 
about four years, with empyema of the left side. 

In large effusion, the mediastinum is pressed against the healthy lung 
so as to diminish its transverse diameter, and Traube has shown that 
the effect of this is to increase the length of the lung, or its vertical 
measurement. Consequently as the lung on the healthy side extends 
lower than in the normal state, the convexity of the diaphragm on this 
side is diminished, as well as on the affected side, where it is depressed 
by the effusion. 

The pleura in protracted cases of empyema becomes much infil- 
trated, and from the growth of connective tissue which blends with it, 
is thickened, sometimes to the extent of one or two lines. A few months 
since, in removing the lungs from the body of a young infant that per- 
ished of empyema in the N. Y. Foundling Asylum, a portion of the 
costal pleura, two or three inches in diameter, being adherent to the 
lungs, was detached from the ribs. It had a thickness of fully two 
lines, and its free surface was rough. 

Occasionally the inflammation extends from the pleura to the pericar- 
dium, producing general pericarditis. I recall to mind four cases with 
this complication, in which the diagnosis was verified by post-mortem 
examinations. All had empyema, three on the left, and one on the 
right side. Pericarditis, always a grave disease, is almost necessarily 
fatal when thus occurring as a complication of empyema. More rarely 
the inflammation extends from the pleura to the peritoneum. One such 
case occurred in my practice, the child dying of empyema on the right 
side, and at the autopsy we found the lesions of a localized diaphrag- 
matic peritonitis of the right side, with a. fibrinous exudation of small 
extent on the convex surface of the liver, directly opposite to that on 
the diaphragm. We are indebted to Yon Recklinghausen for knowl- 
edge of the mode in which inflammation is propagated from the pleura 



HEMORRHAGIC PLEURITIS. 635 

to the peritoneum, and the same explanation probably applies to its 
propagation to the pericardium. In the serous covering of the dia- 
phragm, pleural and peritoneal, minute stomata have been discovered, 
which pertain to the lymphatic system. They open upon the surface 
of the diaphragm, and underneath in the substance of the diaphragm 
connect with lacunae or interspaces, from which the minute lymphatic 
vessels originate. These stomata and lymphatic spaces, pervious in 
their normal state, are usually clogged, as has been stated above, by in- 
flammatory products, when the serous membrane is inflamed. Occa- 
sionally the inflammation traverses these lymphatic channels from one 
surface to the other, from the pleura to the peritoneum, thus causing by 
extension a circumscribed peritonitis. 

The changes which the inflammatory products undergo are the follow- 
ing : With the abatement of the inflammation, the liquid portion begins 
to be absorbed, though absorption is much more tardy than in non-in- 
flammatory effusions, since the absorbents are to a great extent covered, 
and clogged by fibrin and pus. The serum is first absorbed, and the 
flocculi of fibrin sink into depending portions of the cavity, or become 
attached to the fibrinous layers or the granulations upon the pleural 
surface. The pus-ce]ls and the fibrin, whether in flocculi or layers, 
begin to undergo retrogressive change. They become granular from 
fatty degeneration, liquefy, and are absorbed. Sometimes portions of 
these degenerated products, which are not absorbed, form inert caseous 
masses, in recesses of the cavity, or between the bands of connective 
tissue, where they remain unchanged for years. With few exceptions, 
those who recover from an attack of pleuritis experience no subsequent 
ill-effect, though the bands and patches of connective tissue are perma- 
nent. 

Pus always possesses irritating properties. Decomposed and putrid 
pus (ichor) is very irritating. Empyemic pus, therefore, like pus in 
other situations, now and then produces ulceration or necrosis of the 
pleural surface by which it is confined, and in consequence of its de- 
structive action it sometimes establishes an outlet by which it escapes, 
with relief of the patient and cure of the disease. The chest wall is 
thinnest anteriorly, in the inframammary region, and at this point the 
pus, when it makes its way through the thoracic wall, usually points 
and discharges. The fistulous opening thus produced continues many 
months, until the pleural cavity is gradually obliterated by the adhe- 
sions, and the patient recovers. 

By a similar destructive process in the pulmonary pleura, pus occa- 
sionally escapes into the bronchioles, and is expectorated. This mode 
of cure appears to be common in children, for my attention has not in- 
frequently been called to the fact that children, during the progressive 
but slow convalescence from empyema, expectorated large quantities of 
muco-pus, although in some of the cases pus had been removed by the 
aspirator or trocar. Fraentzel makes the remark, which is fully sus- 
tained by clinical experience in this country, that although an opening 
is made in the lung by the necrotic or ulcerative process, so that pus 
escapes into the bronchioles, air does not pass from them into the pleural 



636 PLEUBITIS. 

cavity. Pyopneumothorax is very rare in the empyema of children, 
except as air is admitted in the operation of thoracentesis. 

As the liquid is absorbed, the compressed lung ordinarily expands in 
proportion to the absorption, so that more and more air enters its alve- 
oli. But frequently, in cases of long duration, the absorption proceeds 
faster than the expansion, so that the ribs on the affected side sink be- 
low their normal level. As a consequence, the intercostal spaces are 
narrowed, the shoulder is depressed, and the dorsal portion of the spinal 
column bends to accommodate the ribs so as to be concave toward the 
affected side. It is very rarely that the deformity thus produced is per- 
manent. Though the newly formed bands and patches of connective 
tissue may so bind the lung that its return to the normal state is tardy, 
yet, with few exceptions, the alveoli one after another open to admit 
air, and when full inflation is attained the symmetry of the chest is 
restored. But there are rare cases in which the newly formed connec- 
tive tissue is firm and unyielding almost as cartilage, and lime salts are 
sometimes deposited in it, forming a calcareous plaque, which invests 
the lung like a cuirass. An unexpanded lung, with such a covering, 
obviously can never afterward be fully inflated. I can recall to mind, 
however, only one case of permanent complete collapse or carnification 
of lung, resulting from pleurisy. The inflammation, wdiich was treated 
by the late Dr. Cammann, occurred in childhood, and several years 
afterward, when the patient reached womanhood, although the general 
health was good, there were physical signs of an unaerated lung, and 
the consequent deformity (depressed shoulder and ribs, and bent spinal 
column). Pleurisy with its granulations and retrogressive products 
affords one of the conditions in which tubercles are developed, so that 
we sometimes find at the post-mortem examination of cases which have 
been protracted, " miliary tubercles in the pleura, while chronic phthisis 
and general tuberculosis are absent " (Delafield). 

From the intimate relation of the heart to the lungs, this organ 
obviously suffers severely in every large pleuritic exudation. Total 
compression of a lung arrests one-half of the circulation through the 
pulmonary artery, except as the increased flow in the opposite lung 
serves for compensation. Hence, in cases of large effusion, which end 
fatally, we commonly find the pulmonary artery and the right cavities 
of the heart distended with blood and clots, while the left cavities, 
having received a diminished quantity of blood, are probably empty. 

Symptoms. — As has been stated above, pleuritis in children is some- 
times latent, or. attended by symptoms so mild as to attract little atten- 
tion, even when there has been general inflammation of the pleural sur- 
face with much effusion. Both primary and secondary pleuritis may 
present this form, latency being more frequent the younger the patient. 
In feeble, cachectic children, with blood thin and impoverished, pleu- 
ritic symptoms, as pain, dyspnoea, and fever, are less pronounced than 
in the robust, and, hence, latency is more common in the tenement- 
house population of the cities and in institutions than in the better 
walks of life. The following is a not infrequent example of latency. A 
feeble infant, aged five months and twenty-eight days, died suddenly in 
the Nursery and Child's Hospital, in December, 1870. The attention 



SYMPTOMS. 637 

of the resident physician had not been called to it, as it was not sup- 
posed to be sick, except that it was ill-nourished and its general condi- 
tion bad. The nurse who had charge of the ward stated that it presented 
no symptom of acute disease, unless a slight cough during the three or 
four days preceding its death. Percussion over the right side of the 
chest of the corpse gave a flat resonance, and at the autopsy the right 
lung was found compressed, nearly or quite destitute of air, and cov- 
ered by a loose fibrinous layer, three-fourths of an inch thick in places, 
and a moderate serous exudation. 

Ordinarily acute idiopathic pleuritis in children begins quite abruptly, 
and with symptoms which attract attention from the first. Probably in 
most instances it is preceded by rigors, or a chilly sensation, but this 
usually escapes notice, if it be present, in patients under the age of five 
or six years. Fever, fretfulness, and a physiognomy indicative of pain 
are the common initial symptoms. If the patient be an infant, the 
fretfulness closely resembles that produced by colic, for which I have 
on several occasions known it to be mistaken by the attending physi- 
cians. 

The symptoms of pleuritis are twofold, namely, the constitutional, or 
such as are common to all inflammations, and the local, or those refer- 
able to the chest. Various observers have noted the position in which 
patients lie in bed, as indicating the seat of the inflammation. It has 
been stated that adults, in the commencement of pleuritis, ordinarily 
obtain most relief with a decubitus on the sound side,, but when eifusion 
has occurred they lie on the affected side, unless there be marked dys- 
pnoea, which is most relieved by a semierect position, which allows 
greater descent of the diaphragm. I have not noticed that children 
with pleuritis prefer any fixed or uniform position, except there be 
marked dyspnoea, which may prompt them to elevate the shoulders. 
The patient in the acute stage is commonly quiet when he lies in the 
position which he selects, and if disturbed from it becomes more fretful, 
his cough more frequent, and his suffering apparently increased. 

In ordinary cases, the temperature rises on the first day to 102° or 
103°. If it be more elevated than this, there is usually a complica- 
tion. The fever begins to abate when the exudation has occurred. In 
suppurative pleuritis, the febrile movement is more protracted, often con- 
tinuing for weeks or months, presenting, after the acute stage has passed, 
the characters of hectic fever with morning abatement and evening re- 
crudescence. In weakly and anaemic children, even when the pleuritis 
is pretty severe, and most of the usual symptoms are present, the tem- 
perature may be but slightly elevated. Thus, in one of the institu- 
tions with which I am connected, a young infant, whose fretfulness was 
during the first twenty-four hours ascribed to colic, the axillary tem- 
perature during the first three days never rose above 100°. 

The pulse in the acute stage is usually between 100 and 130 per 
minute, but in young children who are restless it is often more frequent 
than this during the first week. It is accelerated as long as the tern- 
perature is elevated, but in sero-fibrinous pleuritis, after exudation has 
occurred, its frequency diminishes unless the heart be compressed. Com- 
pression and imperfect or partial filling of the cavities of the heart pro- 



638 PLEURITIS. 

duce a feeble and rapid pulse. In empyema the pulse is accelerated as 
long as pus is confined in the pleural cavity, unless its quantity be small. 

Headache, usually frontal, is frequent during the febrile stage. Con- 
vulsions, which occasionally occur in the beginning of pneumonitis, are 
rare. Pain in the chest, on the affected side, is common, and is, there- 
fore, a valuable diagnostic symptom, but it is often so slight as to be 
overlooked in infants and feeble children. It is increased by move- 
ments of the chest-walls, as in full inspiration, by coughing, and when 
pressure is made by the fingers in the examination. Its common seat is 
between the fifth and eighth ribs, external to the linea mammalis, but 
there are many cases in which the pain is referred to some other part, 
as the infraclavicular, mammary, inframammary, or even the scapular 
or infrascapular region. Rarely, it is referred to the epigastric or um- 
bilical region, or even, it is said, to some point upon the sound side of 
the thorax. This location of the pain at a point distant from the seat 
of the inflammation is attributable to the anastomosis of the intercostal 
nerves with those of the opposite side of the chest, or with those which 
ramify in the abdominal walls. 

The pain of pleuritis, as it ordinarily occurs, has received different 
explanations. It has been attributed to tension of the pleura, to fric- 
tion of the pleural surfaces on each other, and to extension of the in- 
flammation to the neurilemma of the minute nervous branches of the 
pleura. All these causes apparently act in producing it, but the per- 
sistent pain in the first days of pleuritis, though increased by motion, is 
probably due in great part to that, last mentioned. Pleuritic pain is 
sharp or stitch-like. It begins to abate in a few days, and in a large 
proportion of cases ceases by the fifth or sixth day, or is no longer 
noticed except in coughing or during sudden movement of the chest. 

The respiration is accelerated, as in all febrile diseases, but it is more 
rapid than in inflammatory ailments which do not involve the thoracic 
organs, on account of the pain experienced on full inspiration. The 
patient instinctively avoids full inflation of the lungs, and the breathing 
is consequently rapid, to compensate for incompleteness of the inspira- 
tory act. 

In ordinary attacks of pleuritis, painful and hurried respiration is of 
short duration. It becomes easier and more natural toward the close 
of the first week. In subacute and chronic cases, the rhythm and fre- 
quency of respiration differ but little from the normal. 

A cough, whatever the form of pleuritis, is one of the earliest symp- 
toms. It is short, frequent, and dry, and in the most favorable cases 
begins to diminish in the second week. A loose cough is due to accom- 
panying bronchitis, or broncho-pneumonitis, or, at a late stage of the 
disease, to escape of pus from the pleural cavity into the bronchial tubes. 

Little need be said in regard to symptoms referable to the digestive 
apparatus. Vomiting is common on the first and second days. Thirst, 
loss of appetite, and consequent loss of flesh and strength, are uniformly 
present. In empyema, which, from its nature, is protracted, nutrition 
is always greatly impaired. The surface presents an anaemic appear- 
ance, the flesh is soft and flabby, and the emaciation is progressive till 
the pus is evacuated. 



PALPATION. 639 

Physical Signs. — In children above the age of three or four years, 
the physical signs differ but little from those in adult cases, but under 
this age there are certain differences which the practitioner should know. 
We may, in the commencement of the attack, notice diminution in the 
movement of the chest-walls on the affected side, since the patient in- 
stinctively endeavors to repress respiration on that side, in order to 
lessen the pain. In severe cases, the epigastrium and hypochondria are 
sometimes depressed during inspiration (the so-called abdominal respira- 
tion), but this sign is less common and less marked than in severe bron- 
chitis, and when present it may be largely due to accompanying bron- 
chitis. After effusion has occurred, and the pain has abated or is slight, 
the respiration is less accelerated than at first, and it may be nearly or 
quite normal. 

Inequality of the two sides produced by the liquid is more common 
in children of an advanced age than in those under the age of three or 
four years. In infants, even when there is a large liquid exudation, the 
bulging is often so slight that it is scarcely appreciable, either by sight 
or measurement, and in not a few there is no apparent difference in the 
circumference of the healthy and affected sides. I have made meas- 
urements in infantile pleuritis during the stage of effusion, and been 
unable to convince myself that there was any difference, although other 
signs indicated the presence of an effusion which filled at least one-half 
the pleural cavity. I explain this fact in this way. The lungs of an 
infant, especially of one reduced by sickness, are very liable to a state 
of semi-collapse or partial inflation in their whole extent, and of com- 
plete collapse of their thin borders, as of the tongue-like process of the 
left upper lobe, which lies over the pericardium and of the margins of 
the lower lobes, which lie on the angle made by the thorax or diaphragm. 
This occurs in the weakly infant, even when there is no obstruction to 
the entrance of air, and the liability to it is greatly increased by ex- 
ternal pressure applied to the lung, as from a pleuritic effusion, so that 
the lung recedes, becomes compressed, and unaerated, before the ribs 
yield to the pressure. If the exudation cease as soon as the lung is 
collapsed, there is little or no outward displacement of the ribs, and the 
intercostal spaces are not elevated. It is obviously very important to 
know this difference between infantile and adult cases, as it has a bear- 
ing upon the diagnosis between pleuritis with effusion and pneumonitis. 

Palpation. — In adults, and in children with strong voices, if the 
lung, deprived of air either by compression or an exudation within its 
alveoli, lie against the chest- wall, speaking or moaning produces a vib- 
ratory sensation which is communicated to the hand placed upon the 
chest. The fremitus is feeble or not appreciable when the voice is 
feeble. Therefore, in infants -whose vocal cords are small, and particu- 
larly in infants reduced by sickness, this sign is ordinarily absent, or so 
slight that it is detected with difficulty, while in older and robust chil- 
dren it is distinctly perceived. If the condition be otherwise favorable 
for the production of fremitus, but the lung be pressed away from the 
ribs by an intervening liquid, no vibration is felt when the patient 
speaks or cries. But if, in the same case, the fingers be removed to the 
suprascapular, axillary, infraclavicular, or mammary region, where the 



6-iO PLEUEITIS. 

compressed lung comes in contact .with the walls of the chest, fremitus 
may be perceived. Palpation also enables us to ascertain the point of 
apex-beat of the heart, variation of which from the normal site being 
one of the most conclusive proofs of a pleuritic effusion. 

Percussion. — In the first hours of pleuritis, there is either no per- 
ceptible change in the percussion sound, or the resonance is slightly 
diminished, from the fact that inspiration on the affected side is resisted 
by the patient, and the lung is only partially inflated. When exuda- 
tion occurs, if there be a thin layer of liquid over the lung, the percus- 
sion sound is tympanitic. It has, therefore, this quality at an early 
stage in the inframammary, mammary, and perhaps infrascapular 
regions, when the amount of liquid is small, and at a later stage, when 
the quantity of liquid is greater, the percussion sound over the lower 
part of the chest is dull, while that over the central or upper part is 
tympanitic. Entire filling of the pleural cavity with liquid, and total 
exclusion of air from the lung, give rise to a dull or flat percussion 
sound over every part, from the apex to the base. It may be stated as 
a rule in the pleuritis of children that, at a certain stage of the effusion, 
percussion produces a sound which is either decidedly tympanitic or 
which partakes of the tympanitic character. Skoda attributed the oc- 
currence of tympanism to the fact that a lung still aerated vibrates 
better if surrounded by a thin layer of liquid, and consequently gives 
better resonance than when it lies against the chest-walls. 

When the exudation is so great that the lung is totally compressed, 
and removed to a distance from the chest-walls, the finger in percussing 
experiences a sensation of solidity or resistance, and there is no longer 
any vibration of the ribs. Consequently the percussion sound is dull 
or flat, as over any solid body, differing from that in pneumonitis, in 
which there is still some vibration of the chest-walls, and the dulness is 
not absolute. In pleuritis, therefore, there is, according to the amount 
of exudation, either nearly the normal percussion sound, as at the be- 
ginning of the attack and in any stage of plastic pleurisy (pleuresie 
seche), or a zone of dull sound below, and another of tympanitic sound 
above, or a zone of normal resonance above, and one of dull resonance 
at the base, with an intervening one of tympanism, or, finally, there is 
absolute dulness from the clavicle to the base of the chest. 

It very rarely happens in the child that the level *of the fluid changes 
by changing the position, on account of the adhesions, so that this sign, 
described in the books as one of great importance in diagnosis, affords 
very little assistance to diagnosis in children. 

Auscultation. — In the beginning of pleuritis, auscultation affords 
but slight information, except that the practised ear may detect a little 
diminution in the fulness of the respiratory act in the lung, whose 
pleura is inflamed, and perhaps a slightly exaggerated respiration in 
the other lung. But after twelve or fifteen hours, when exudation be- 
gins to occur upon the pleural surface, we may hear the dry friction 
sound, which can be imitated by pushing the finger strongly across the 
dry palm of the hand. It is only heard in occasional cases, since the 
physician may not make his visit at the proper time for hearing it, or 
he does not apply the ear over the proper place. Fraentzel says: 



AUSCULTATION. 641 

" "We shall scarcely ever fail to find the friction sound, in recent pleu- 
ritis, if we look for it early and diligently in some circumscribed spot." 
I do not think that this remark, however true it may be of adult cases, 
is entirely correct as regards children, for it is only in exceptional in- 
stances that it can be heard in them. It occurs both during inspira- 
tion and expiration, and it does not disappear after coughing. Being 
produced upon the surface of the lung, it seems near the ear of the aus- 
cultator. Perhaps it is not observed during several consecutive respira- 
tions, and then a deeper inspiration causes the pleural surfaces to glide 
upon each other, and it is detected. The friction sound as sometimes 
heard is well expressed by the term scraping, and in other cases by the 
term creaking, as was noticed by Hippocrates, who compared it to the 
creaking of leather. 

In some patients it is heard for a brief period and does not recur, and 
it may be detected only during strong and deep respiration or in cough- 
ing. It disappears entirely when the accumulation of liquid prevents 
contact of the surfaces. After absorption of the liquid, the friction 
sound may reappear, and in certain patients it is heard only at this 
time, to wit, in the third stage. 

An interesting and common sound heard on inspiration is the so- 
called crepitant rale of pleurisy, produced in the superficial alveoli. 
The remarks made by Trousseau upon it have been already given. As 
stated above, the inflammation extends from the pleura to the pulmonary 
vesicles which lie directly underneath, and as soon as exudation occurs 
within them, the anatomical conditions are present in which the crepi- 
tant rale is produced, as in the ordinary form of pneumonitis. This 
rale may obviously be heard before any effusion takes place upon the 
free surface of the pleura, and it continues until the alveoli are so com- 
pressed by the pleuritic exudation that they no longer admit air. 

The exudation in the pleural cavity changes the character of the res- 
piratory sound. A thin layer of liquid over the lung causes diminution 
in the force of the vesicular murmur, and soon an expiratory as well as 
an inspiratory sound begins to be heard. This modified vesicular mur- 
mur is weak, and more distant from the ear than the respiratory sound 
of health. When the exudation is sufficient to close the alveoli, while 
the air still traverses the medium-sized bronchial tubes, we notice a 
tubular or bronchial bruit. If the small and medium-sized tubes are 
compressed, while the air enters the large tubes, the respiratory bruit 
may be amphoric. Total absence of respiratory sound results from 
complete collapse of the alveoli, and consequent exclusion of air from 
them, and arrest of the movements of the air in the tubes of the affected 
side. Jaccoud says: " Regarded as a sign of the quantity of the effu- 
sion, the modifications of the respiratory bruit, and of the respiration, 
may then be arranged, in an increasing series as follows : diminution 
of the vesicular murmur ; feeble respiration {souffle cloux) ; no sound, 
and feeble respiration ; bronchial respiration ; no sound, and bronchial 
respiration ; no sound, and cavernous respiration ; general absence of 
sound {silence general). The replacement of an inferior term of the 
series by a superior term implies an augmentation in the quantity of 
liquid, and in general the passage of a superior term to an inferior term 

41 



642 PLEURITIS. 

denotes a diminution of the effusion." But this statement relating to 
the effect upon the auscultatory sounds of the increase and decrease of 
the liquid must be modified as regards patients under the age of five 
years. In such patients it is rare, however great the effusion, that res- 
piration is not heard when the ear is placed over the liquid. This is 
due to the small size of the pleural cavity, and the consequent ready 
transmission of sound from the centre of the thorax to its periphery. 
According to the amount of exudation and the degree of compression, 
the respiratory sound is a faint and distant vesicular, or broncho-vesicu- 
lar, or bronchial murmur, and its character is found to vary from one 
to the other of these sounds, as we apply the ear over different parts of 
the chest. 

When the inflammation is active, and the exudation occurs rapidly, 
bronchial respiration may be heard as early as the second or third day, 
or even by the close of the first day, in the infrascapular region. If, 
on the other hand, the inflammation be chiefly plastic, or the exuda- 
tion of liquid be slow, and its quantity small, the respiratory murmur 
may be vesicular, though faint and distant, during the whole course of 
the attack. Sometimes when the murmur is vesicular in the greater 
part of the lung, broncho-vesicular or bronchial respiration is heard 
over a limited area, where the effusion happens to be suSicient to pro- 
duce requisite compression of the lung. 

The voice of the patient, when auscultated over the affected side, 
has a character which corresponds with and varies according to the res- 
piratory murmur. Vocal resonance is feeble or absent if the respira- 
tory murmur be vesicular. If it be bronchial, the auscultated voice is 
more distinct, having the character known as bronchophony, or when 
there is a moderate quantity of liquid over the lung, so that this organ 
vibrates, it may have that modification of bronchophony known as lego- 
phony. Occasionally we can hear the voice as a confused and distant 
sound, when the quantity of liquid is so great that respiration is in- 
audible. The signs derived from the auscultated voice are not, as is well 
known, pathognomonic of liquid effusion. Bronchophony is more com- 
mon and distinct in pneumonic or tubercular solidification of lung than 
in pleuritis, and even aegophony may be produced without the presence 
of a liquid, by " pleural membranes realizing certain physical con- 
ditions" (Jaccoud). But since the auscultated voi'ce is weaker in chil- 
dren than in adults, we often do not hear it in infants and ill-conditioned 
children, even when the anatomical conditions, as regards the lungs and 
pleural cavity, are favorable for its transmission. 

In children as in adults, bronchial rales are common in pleuritis, dry 
or moist ; coarse when produced in the larger tubes, or fine when 
occurring in the finer tubes. 

Diagnosis. — Ordinarily, a careful observance of the history, symp- 
toms, and physical signs enable the physician to make a positive diag- 
nosis. Obscure or doubtful cases occur chiefly in infancy. Circum- 
scribed pleuritis, or pleuritis attended w T ith little or no liquid exudation, 
is obviously likely to be overlooked, and .its symptoms mistaken for 
another disease. 

Pleuritis, before the stage of exudation, may be mistaken for pneu- 



DIAGNOSIS. 643 

monitis, since the prominent symptoms in the commencement of the 
two diseases are similar. But in pleuritis there are commonly greater 
acceleration of pulse and respiration, greater suffering, as evinced by 
the features, greater tenderness on percussion, or on pressing the chest- 
wall, and a more decided expiratory moan, while the patient probably 
endeavors to repress respiration on the affected side, so that inflation of 
the lungs is partial and shallow. It will aid in the diagnosis to recol- 
lect that, in children under the age of five years, acute pneumonitis is, 
in most instances, catarrhal, and not croupous, and is preceded and 
accompanied by severe bronchitis, being due to downward extension of 
the inflammation from the bronchial tubes. It therefore does not begin 
with the abruptness of pleuritis. 

Pleuritis with effusion may be mistaken for pneumonitis in the stage 
of solidification, for hydrothorax, or, on the left side, for pericardial 
effusion, or vice versa. But the percussion sound over a pleuritic exu- 
dation is either tympanitic or flat, while over a lung solidified by inflam- 
mation it has some resonance, though dull. There is also a sensation 
of greater resistance and solidity in percussing over a pleuritic exucla= 
tion than over an inflamed lung. Moreover, the respiratory murmur, 
whether vesicular, broncho-vesicular, or bronchial, is more distant and 
less distinct to the ear of the auscultator when applied over a liquid 
than over a solidified lung. 

A pleuritic exudation, unless slight, also changes the apex-beat of 
the heart, pressing it toward the median line in left pleuritis, and away 
from the median line in right pleuritis, as has been stated above — a 
change not observed in pneumonitis. Bulging of the intercostal spaces, 
expansion of the chest- walls, change in the height of the fluid by change 
in the position of the child, important signs in the diagnosis of adult 
pleuritis are, as we have seen, commonly absent in young children, even 
when there is abundant liquid effusion, but they are sometimes observed 
in children of a more advanced age. Bronchophony and vocal fremitus, 
signs of pneumonic solidification, are absent, or so feeble in the pneu- 
monitis of young children that their absence cannot be regarded as 
indicative of the presence of pleuritic effusion, except in children over 
the age of four or five years. Moreover, these signs, when present, do 
not necessarily indicate pneumonitis, for if, in pleuritic effusion, the ear 
or hand be place! over a part of the chest where adhesions have united 
the lung to the ribs, and the child be of such an age that the vocal cords 
have sufficient vibration, both bronchophony and the fremitus may be 
perceived. The absence or presence, therefore, of vocal fremitus and 
bronchophony affords only limited assistance in the differential diagnosis 
of pleuritis and pneumonitis in young children. In those of an ad- 
vanced age whose vocal cords have greater vibration it aids in the dis- 
crimination of doubtful cases, especially if the examination be made in 
the infrascapular region, which corresponds with the location of the 
liquid, if any be present. 

A pleuritic effusion is distinguished from hydrothorax by the fact 
that the latter is usually bilateral and of slow increase, without symp- 
toms referable to the chest, except when there is considerable effusion, 
which causes more or less dyspnoea. Pleuritis, unlike hydrothorax, 



644 PLEURITIS. 

causes fever and otner constitutional symptoms, and also a cough, pain 
in the chest, and early embarrassment of respiration. Moreover, hydro- 
thorax seldom occurs, except from cardiac or renal disease, or scarlet 
fever. 

A greatly distended pericardial sac simulates, in some degree, a pleu- 
ritic effusion on the left side, but the absence of symptoms which pertain 
to pleuritis, as the cough, stitch-like pain in the chest, the localization 
or greater distinctness of the dull sound on percussion, in the cardiac 
region, absence or feebleness of the apex-beat, and indistinctness or dis- 
tance of the heart sounds, will preserve the observant, physician from 
error of diagnosis. 

Prognosis. — In mild cases attended with little exudation, the inflam- 
mation soon begins to abate, and, by the close of the second week, the 
symptoms have nearly disappeared. In plastic and sero-fibrinous pleu- 
rises, recovery may be confidently expected, unless there be some grave 
complication, or perchance syncope should occur from large and rapid 
effusion. A large effusion, whatever its character, especially if located 
on the left side, often causes such a twist in the great vessels within the 
thorax as seriously to retard the circulation of blood and endanger life. 
In effusions of the left side, the heart is often carried so far toward the 
right that the ascending vena cava, where it emerges from the central 
tendon of the diaphragm, is bent at an angle. so as seriously to obstruct 
the return of blood from the lower half of the body, and consequently a 
reduced quantity of blood reaches the right cavities and the pulmonary 
artery. The result is a diminished flow of blood in the systemic circu- 
lation, with anaemia of important organs, as the brain. The great arte- 
ries connected with the heart are also more or less bent in cases attended 
by displacement of this organ. In effusions on the right side, the right 
auricle and ventricle sometimes do not expand to the normal extent 
during the diastole, on account of the pressure of the liquid, and the 
result is similar to that in effusions on the left side, as regards obstructed 
circulation and ansemia of important organs. Therefore, patients with 
large pleuritic effusions, whether left or right, are liable to sudden faint- 
ing and even to fatal syncope. Fortunately, with our present improved 
methods of thoracentesis, children need not perish in this way if the 
operation be resorted to at the proper moment. There is another 
danger. When, in consequence of the exudation, the lung is so com- 
pressed that its function is nearly or quite lost, the sound lung obviously 
receives an augmented supply of blood. It is, therefore, very liable to 
sudden congestions and transudation of serum (oedema). If this occur, 
the dyspnoea is augmented and the condition is one of utmost peril. 
Death may result from this state. 

The prognosis obviously varies according to the cause of the inflam- 
mation and the quantity and nature of the exudation. Idiopathic pleu- 
risies do better as a rule than those which occur as a complication or 
sequel of some other disease. Absorption is more rapid in the begin- 
ning of convalescence, when the fluid is thin, than at a later period, 
when it has greater consistence. Fibrin, whether flocculent or lamin- 
ated, is necessarily slowly absorbed, first undergoing fatty degeneration 
and liquefaction. Empyema, if not relieved by operative measures, 



PROGNOSIS. 64:5 

continues many months, and even after pus is let out convalescence is 
slow. In the very considerable number of em pyemic cases which have 
from time to time been brought to the class of children's diseases in the 
Bureau for the Relief of the Outdoor Poor, the histories commonly 
showed that the disease had continued from three to six months, with 
progressive loss of flesh and strength. Nevertheless, after proper 
evacuation of the pus and establishment of a fistulous opening, the 
majority have gradually recovered, death in the unfavorable cases being 
commonly due to extreme prostration with perhaps fatal organic 
changes, as amyloid degeneration and tuberculosis. 

Secondary pleuritis occurring in a reduced state of the system, as 
after scarlet fever, and pleuritis complicated by a grave disease, as peri- 
carditis or pneumonia, are always dangerous to life. 

It is the common belief that pleuritic effusions involve greater danger 
on the left than on the right side, from the fact that the former pro- 
duces more immediate and direct pressure on the heart and causes a 
greater twist in the vessels, but Leichtenstern 1 states that, in 52 cases 
of sudden death from pleuritic effusions, 31 were right and 20 left 
pleurises. The walls of the right cavities of the heart, upon which the 
liquid in the right pleural cavity directly presses, are thinner and there- 
fore more yielding than the walls of the left cavities. The records of 
the cases collected by Leichtenstern show that sudden death sometimes 
results from extensive and far-reaching thrombi in the right cavities of 
the heart and in the superior vena cava, or to emboli detached from the 
thrombi and intercepted in the pulmonary artery. In grave cases at- 
tended by large effusion, sudden death sometimes occurs after some 
exertion on the part of the patient, as after vomiting, severe coughing, 
or hurried rising to the erect position, or lifting a heavy weight. It is 
believed that, under such circumstances, there is a retarded flow of 
blood through the lungs and into the left cavities of the heart and the 
aorta, so that sudden and fatal anaemia of the brain is produced. 

As already stated, death may occur in protracted cases from amyloid 
degeneration of important organs, as the kidneys and liver. This can 
sometimes be detected by enlargement of liver and spleen, and the oc- 
currence of albuminuria. 

It is evident that the prognosis varies greatly according to the degree 
of dyscrasia. In profound blood-poisoning, whether scarlatinous, urse- 
mic, or septicemic, pleuritis is always grave. • Septic pleuritis, which 
occurs for the most part in newborn infants, during epidemics of puer- 
peral fever is especially so. When it has continued a few hours, the 
pinched features and rapid sinking show that we have to deal with 
something more than an ordinary attack. 2 

Pleuritis is also very severe, and ordinarily fatal, when it is caused 
by the entrance of some pathological product into the pleural cavity, as 
pus or decaying lung substance. 

1 Deutsches Archiv fur Klin. Med., Band iv. 

2 The following case, which occurred in my practice during the recent epidemic 
of puerperal fever (1881), may be adduced as an example: Mrs. D., a primipara, 
was delivered by the forceps after a tedious labor, at 9 p.m., April 6th. On the 
following morning her temperature, without the occurrence of a chill, had risen to 



64(3 PLEURITIS. 

Treatment. — It will be convenient, in considering the treatment, to 
describe that which is appropriate for each of the three stages into which 
systematic writers have divided pleuritis: First, the stage preceding 
effusion; secondly, that of effusion; and thirdly, that of absorption and 
convalescence. In the beginning of the inflammation, appropriate 
measures should be promptly employed for the purpose of reducing the 
inflammation, and preventing or diminishing, so far as possible, the exu- 
dation that soon follows. The abstraction of blood is now properly dis- 
carded in the treatment of most inflammations of infancy and childhood, 
but in certain cases of pleuritis occurring in robust children over the 
age of four or five, or even three years, the early and judicious employ- 
ment of one or two leeches diminishes the pain and apparently also for 
a time the febrile movement and the inflammation. But it may be 
stated as a rule that the loss of blood is not only not required, but is in- 
jurious in all secondary pleurisies, and in the primary form after exuda- 
tion has occurred. It is injurious in all forms of pleuritis in pallid and 
cachectic children, and, therefore, in a large proportion of the cases oc- 
curring in the tenement-houses and institutions of the cities. The flow 

105J°, and her pulse varied between 125 and 134. She was in a critical state for 
several days, with a temperature varying between 103° and 105J°, and without any 
local symptoms either of metritis or cellulitis, but finally recovered. The baby, 
healthy and vigorous at birth, had been allowed to obtain what nutriment it could 
from the breast, but the nurse remarked that she " never saw a child sleep so 
much," and I gave very little attention to it, as my time was devoted wholly to 
the mother. On the 10th, when four days old, its sleepiness ceased, and it became 
constantly fretful, as from colic, and it refused to draw upon the nipple. Early in 
the morning of the 11th I was summoned to it, and was astonished at its altered 
appearance, its shrunken features, and its evidently dying state. Percussion upon 
the right side gave a flat resonance from the clavicle to the diaphragm, and there 
was some meteorism in the abdomen. The thermometer introduced into the rectum 
showed no elevation of temperature, and no unusual heat of surface or cough had 
been noticed by the nurse. By active stimulation the infant lived till the middle 
of the afternoon. The autopsy revealed a sero-fibrinous exudation filling the right 
pleural cavity, producing complete carnification of the lung, so that it resembled 
that of the fcetal state, and soft patches or flakes of fibrin upon the lungs. By an 
oversight, the peritoneum was not examined. Cases like this, of pleuritis in the 
newborn, produced, it is thought, by the wandering micrococci of the septic state, 
occur chiefly during epidemics of childbed fever. Some years ago I saw a newborn 
infant in one of the institutions, whose mother had puerperal fever, die in a similar 
manner, and the autopsy showed that the cause was peritonitis. The following ex- 
tracts from Trousseau's clinical lecture on erysipelas of newborn infants will aid in 
understanding such cases. Speaking of Dr. P. Lorain, he says : " During the epi- 
demic at the maternity, where this ableand laborious observer was a resident pupil, 
he collected the information of which the following is a summary : Of 106 stillborn 
infants, 10 were found to have died from peritonitis, and 3 of the mothers of these 
10 infants were carried otf by puerperal fever after delivery. Of 193 infants born 
alive, 50 died of the very same affections which proved fatal to the lying-in women. 
The most frequent causes of death were peritonitis, numerous abscesses, purulent in- 
fection, phlegmonous swellings, erysipelas, gangrene of the limbs, putrid infection, 
or some other remarkable septic condition." . . . " Mother and child then are sub- 
ject to the same morbific influence." Further on, Trousseau says of the infant 
affected by this puerperal poison : " He will cry incessantly from pain. A state of 
restlessness will be succeeded by collapse, which will close the scene on the fifth, 
sixth, or seventh day. On examining the body after death, pus will be found in 
the cellular tissue, sometimes suppurative pleurisy , more frequently phlebitis of the 
umbilical vein, or of the vena porta, or peritonitis." An interesting incidental 
fact shown by these statistics is that the cause of this puerperal disease of the new- 
born is sometimes operative in the fcetal state. 



TREATMENT. 647 

of blood from the bites if leeches are employed should ordinarily be 
arrested after two or three hours, but if slight it may continue longer in 
vigorous children of eight or ten years. 

At the first visit of the physician, an emollient and slightly irritating 
poultice should be ordered, enveloping the entire chest, to be constantly 
worn, except as it is temporarily removed during the application of the 
leech, and the subsequent flow of blood. The poultice should be so 
mildly irritating that it causes constant redness of the skin without 
pain, and it should not be removed except when a fresh poultice is pre- 
pared to replace it. Thus employed it produces constant dilatation of 
the capillaries of the skin, and, by the fluxion caused, diminishes the 
engorgement of the capillaries of the costal pleura. A poultice of com- 
mon mustard, with flaxseed in powder, one part to sixteen, between two 
pieces of muslin, and so wet that it moistens the hand in holding it, pro- 
duces this effect. Applied morning and evening, it can be constantly 
worn without complaint of pain produced by its irritating action. For 
infants under the age of eight months, I prefer the use of plain 
flaxseed, w T ith camphorated oil smeared upon its under surface. The 
oil may be applied several times daily, while the morning and evening 
application of the poultice is sufficient. Spongiopilin or compresses of 
flannel wrung out of hot water and covered with oil-silk meet the indi- 
cation, and possess the advantage of being lighter and cleaner, and more 
readily applied than the poultice. Redness may be produced by ap- 
plying under the spongiopilin a single thickness of muslin soaked with 
camphorated oil, or for children of a more advanced age, with campho- 
rated oil and one-fourth part of turpentine. 

Vesication, formerly much employed, has properly nearly fallen into 
disuse in the treatment of the pleuritis of children. While it is liable 
to increase the suffering, it has apparently no tendency to diminish the 
inflammation, in whichever stage employed, and there is no certainty 
that it stimulates the absorbents and expedites the removal of the liquid, 
according to the old theory. A case is reported, in the practice of one 
of the New York physicians, in which a blister had been applied when 
the inflammation was still active, and at the autopsy the portion of the 
costal pleura which lay directly underneath the surface that had been 
vesicated was covered by a thicker fibrinous exudation than that upon 
the contiguous surface. The increased afflux of blood caused by the 
blister had, to appearance, extended to the costal pleura, and increased 
the pleuritis. The application of cold bandages around the chest, which 
is recommended by some, seems to aggravate the cough in certain 
patients, and does not ordinarily give the relief of moist and warm ap- 
plications. 

Internal Remedies. — The indications are to employ such medicines 
as diminish the frequent action of the heart, and thus retard, in a meas- 
ure, the flow of blood to the pleura, and such as diminish the pain and 
frequency of the cough, which, by increasing the friction of the pleural 
surfaces, tends to increase the inflammation. For robust children over 
the age of three years in the first stage of primary pleuritis, the tincture 
of aconite may be prescribed, half a drop for a patient of three years, 
and one drop for one of six years, every third hour for two or three 



648 PLEURITIS. 

days, or until the required effect be produced upon the pulse, when it 
should be discontinued. It is, as a rule, too depressing for younger 
patients. Digitalis is a better and safer remedy for children under the 
age of three years, for all secondary pleurisies, and for all cachectic cases. 
Benefit results from continuing the use of digitalis in the stage of exu- 
dation when aconite would be inadmissible. A child of two years can 
take two drops of the officinal tincture, and one of five years four drops 
every two or three hours. 

Antipyrin is the most effectual antipyretic which we possess. One 
or two doses reduce temperature two or three degrees. It therefore 
promises to be a useful remedy in the first stage of pleuritis as well as 
in other acute diseases, when the temperature is so high as to involve 
danger. It is not a tonic, and it seems to impair the digestive function. 
It is, therefore, most useful in those diseases which are not attended by 
any marked prostration, but in which the fever, from its intensity, 
exhausts the strength. If, therefore, in the commencement of pleuritis 
the temperature rises above 103°, it may properly be prescribed in doses 
of four grains to a child of five years, and be repeated, if necessary, in 
three hours. It is soluble in water, and it may be employed as an 
enema if the stomach be irritable. 

The use of quinia is suggested, since it is an antipyretic and tonic, 
but in my practice it has been much less useful in pleuritis than in pneu- 
monitis. This agent, in whatever form given, does not appear to exert 
any notable controlling effect either on the fever or gravity of pleuritis. 
Nevertheless, I have often employed it, especially in secondary pleuri- 
sies, with or without digitalis, and it probably does some good as a tonic. 
The salts of quinia, as ordinarily given in solution to young children, 
are frequently vomited. When vomited, a soluble salt, as the bisul- 
phate, may be given as a suppository, or Squibb's oleate of quinia 
may be employed by inunction. I should, however, add that, though I 
have used inunctions of the oleate in pleuritis during the last year, ten 
grains of the alkaloid, at a time, I have not seen any marked beneficial 
effect. To meet the second indication in the treatment of the first stage, 
namely, to relieve the pain and restlessness, and to diminish the cough, 
so that there is less friction of the pleural surfaces, our chief reliance 
must be on hyoscyamus or one of the opiate preparations. The follow- 
ing formulee will be found useful : 

R. — Tinct. opii deodorat. . . gtt. xx. 

Tinct. digitalis .... gtt. xl. 
Syr. pruni Yirginiani . . Ij. 

Aquee 5J SS - — Misce. 

Dose, one teaspoonful (one drachm) every three hours for an infant of eighteen 
months. The tincture of hyoscyamus may he employed in place of the opiate in 
double the dose. 

For a child of three years : 

R. — Tinct. ipecac, comp. 1 

(Squibb's liquid Dover's powder), i-aa gtt xxxij. 
Tinct. digitalis, j 

Syr. pruni Virginiani . ^ i j — Misce. 

Dose, one teaspoonful every two or three hours. 



TREATMENT. 649 

For a robust child of eight years with primary pleuritis : 

R. — Morph. sulphat gr. j. 

Tine. rad. aconit. ..... gtt. xx. 

Syr. pruni Virginiani .... ^ijss. — Misce. 

Dose, one teaspoonful every three hours. 

The diet in the first stage should consist of milk and farinaceous food, 
given liberally. The meat-teas or the expressed juice of meat may be 
added, and in secondary pleurisies, as after scarlet fever, it is often 
proper to give a moderate amount of alcoholic stimulants from the first. 

Second Stage. — Measures employed in the first stage have been de- 
signed to diminish the inflammation and relieve suffering. The duty 
of the physician, in the treatment of the second stage, is chiefly to aid 
in the removal of the inflammatory product, and prevent, so far as possi- 
ble, its further formation. If this be sero-fibrinous, and its quantity be 
small, so as to fill only the lower portion of the cavity, little aid may be 
needed from therapeutics ; but a larger effusion, compressing the lung 
and displacing the heart, requires medicinal and often surgical measures. 
The recommendations of Niemeyer, that the patient's food contain little 
liquid, and that his drinks be restricted, as a means of increasing ab- 
sorption from the pleural surface, is not applicable to young children, 
whose diet must of necessity be largely liquid, and that of infants chiefly 
milk. 

Attempts to stimulate the absorbents by external treatment of the 
chest are of doubtful efficacy, whether by the application of the so-called 
small flying-blisters, the iodine ointment or tincture, or a stimulating 
liniment. The common practice of treating glandular swellings by 
iodine applications suggests their use for pleuritic effusions, and of the 
agents employed locally to hasten absorption they are probably the best, 
but they should not be used so often or in such quantity as to cause pain 
or restlessness from their irritating effect. 

It is an established principle in therapeutics that the removal of a 
serous liquid in either of the larger cavities of the body is hastened by 
such remedies as produce an abundant liquid secretion or transudation 
from any of the organs or surfaces. Hence in the treatment of pleuritic 
effusions, those medicines which act on the skin causing diaphoresis, 
upon the intestines causing watery stools, and upon the kidneys causing 
diuresis, are at once suggested as most likely to be efficacious. But 
sudorifics, though useful for dropsies having a renal origin, have not 
been much used of late years for the removal of exudations in the pleural 
cavity, experience having shown that they are inadequate for this pur- 
pose. Recently, however, the discovery of a very active agent of this 
class, jaborandi, has revived, in a measure, the sudorific treatment of the 
second stage, so that in the National Dispensatory of Stille and Maisch 
this diaphoretic is one of the recommended remedies. But the heart, 
crippled in its action by the pressure of the liquid, badly tolerates agents 
of a depressing nature, and jaborandi, or its active principle pilocarpin. 
exerts a weakenino* effect on this organ. It therefore should be used 
with caution in this disease. It is probably best, in most instances, not 
to employ it, inasmuch as we possess other and efficient remedies. 



650 PLEURITIS. 

The fact that serofibrinous exudations have been known to diminish 
rapidly during attacks of diarrhoea suggests the use of purgatives ; but, 
although an open state of the bowels, as two or three daily stools, aids 
in absorption, free purgation is badly borne by young or feeble children, 
as it reduces the strength, and, therefore, is not to be recommended as a 
therapeutic measure. Moreever, there is not the need of employing 
severe or exhausting medicines for the removal of the liquid, which 
existed in former times, since we are able to accomplish this quickly, 
easily, and safely by the excellent aspirating instruments now in common 
use. 

Diuretics, on the other hand, are apparently more useful while they 
are less exhausting, than sudorifics or cathartics. Digitalis, combined 
with the citrate or acetate of potassium, has stood the test of experience, 
and is now more widely used than any other agent of this class. Being 
both a diuretic and heart tonic, it possesses properties which render it 
especially serviceable in the treatment of pleuritic effusions. The fol- 
lowing is a useful prescription for a child of five years : 

R. — Potassii acetatis zij. 

Infus. digitalis ....... Jiij. — Misce. 

Give one teaspoonful every three hours. 

It is a matter of observation that absorption occurs more rapidly, and 
a sero-fibrinous is less likely to become a purulent effusion, if the bodily 
condition be good. Hence tonics, especially the bitter vegetables, are 
sometimes useful, and a diuretic in combination with a tonic, as the 
acetate of potassium in decoction of cinchona, may often be prescribed 
w 7 ith advantage. 

Still, however judicious the treatment, hygienic and medicinal, many 
cases require surgical interference, and the number of such is larger in 
the city than in the country, and in tenement-houses than in the better 
w T aiks of life, since the cachexia so common in city children increases 
the liability to purulent exudations. 

Thoracentesis. — The indications for the operation are the following : 

1st. Dyspnoea due to the presence of the liquid, whether it be sero- 
fibrinous, purulent, or hemorrhagic. Usually w T hen dyspnoea occurs, the 
pleural cavity is full, but if there be parenchymatous disease of either 
lung, a moderate quantity of liquid may cause such' embarrassment of 
respiration that thoracentesis is indicated. 

2d. A flat percussion sound over the entire affected side, with dis- 
placement of the heart, even if there be no present dyspnoea, is also an 
indication for the operation, for dyspnoea may occur suddenly with 
other alarming symptoms between the visits of the physician. More- 
over, experience has shown that absorption from a distended pleural 
cavity is very tardy, in consequence of compression of the absorbents, 
whereas, if a portion of the liquid be removed, absorption of the re- 
mainder is more rapid. The patient with full pleural cavity and lung 
totally compressed lies on the affected side, and is usually uncomfort- 
able in any other position, and the withdrawal of a portion of the 
liquid, as, for example, one half, the operation being discontinued when 
the patient begins to cough or evince distress, produces no ill-effect, and 
increases the comfort. 



TREATMENT. 651 

3d. A moderate effusion, without material decrease in quantity after 
some weeks of observation, also indicates the need of surgical interfer- 
ence, since long compression of a lung involves risks. There is danger 
that catarrhal ending in cheesy pneumonia and tubercles may occur in 
a lung whose function is long suspended ; besides the longer compres- 
sion has existed, the more tardy, difficult, and incomplete will be the 
inflation when the liquid is removed, on account of the altered state of 
the alveoli, and the presence of fibrinous bands over the lung. Thus, 
in a case recently under observation, only partial inflation of 'the lung 
occurred, after letting out the liquid, so that the ribs and shoulder on 
the affected side are permanently depressed, and unequivocal symptoms 
of tuberculosis are now present. 

4th. If the inflammation extend to the pericardium, so as to cripple 
the heart's action, or if there be any serious preexisting heart disease, 
the liquid, even in moderate quantity, may, by pressure, so embarrass 
and retard the heart's action that its cavities are not properly filled, so 
that passive congestion of certain organs, and dangerous anemia of 
others, especially of the brain, may result. Under such circumstances, 
an early performance of thoracentesis is indicated. 

5th. Empyema. — The presence of pus in the pleural cavity affords 
in itself, in a large proportion of cases, sufficient indication of the need 
of thoracentesis. In recent cases, with only moderate constitutional 
disturbance and embarrassment of respiration, if we ascertain by the 
hypodermic syringe that the liquid is only slightly clouded by leuco- 
cytes, surgical interference may be postponed, while the acute inflam- 
mation is treated. Thus, in case of an infant of two months, thin pus 
was withdrawn on the fourth day of acute pleuritis, and, although 
thoracentesis was early performed, it appeared probable, from the 
subsequent course of the case, that it would have been as well had the 
operation been deferred. If spontaneous evacuations of pus have 
occurred through one of the intercostal spaces, producing a fistula, from 
which there is a daily oozing, or if it be probable, from the symptoms 
and signs, that pus is escaping from the pleural cavity into a bronchial 
tube, and is being gradually expectorated — a mode of cure which, as I 
have elsewhere stated, is not infrequent in children — thoracentesis may 
be deferred. In the case of an infant, aged six months, recently under 
treatment for empyema of the left side, we removed four ounces of pus, 
and washed out the pleural cavity. The opening having closed, and 
the physical signs indicating the reaccumulation of a considerable quan- 
tity of liquid, we were preparing for a second operation, when the 
parents and nurse called our attention to the fact that there were occa- 
sional severe attacks of coughing, during which the breath presented a 
very decidedly purulent odor. Although there was no external expec- 
toration, as the sputum was swallowed, thoracentesis was postponed, 
and the result justified the decision, for the patient gradually conva- 
lesced. Except under circumstances like the above, empyema, when 
clearly diagnosticated, by the employment of the hypodermic syringe, 
should be promptly treated by evacuation of the pus. 

Instruments to be Used, and Mode of Operating. — Ingenious instru- 
ments for tapping the chest have been invented by Dr. Chadbourne, of 



602 PLEURITIS. 

*he New York Foundling Asylum, Dr. A. M. Phelps, of Chateaugay, 
Franklin Co., N. Y., and others, which, by India-rubber packing, totally 
exclude air, while the operation is performed with facility and little 
pain. That devised by Dr. Chadbourne has a canula with two arms, 
one for attachment by means of tubing, to the exhausting receiver, and 
the other is designed to facilitate irrigation of the pleural cavity. 

Phelps's apparatus has a third tube, entering the bottle through the 
stopple, and a glass tube passes from the stopple to nearly the bottom 
of the bottle. With this apparatus, by reversing the movement of the 
syringe, the liquid can be withdrawn from the chest, the bottle emptied 
of it, the water used for irrigation be conveyed into the bottle, from the 
bottle to the chest, and back into the bottle, without changing the posi- 
tion of the bottle or removing the stopple. I would suggest the use of 
the trocar and canula instead of the sliding aspirator point which plays 
outside the canula, as an improvement in this instrument. 

The instrument which I have been in the habit of employing is of 
simpler construction. The canula has about the size of the smallest 
needle of Dieulafoy's aspirator; the proper size, in my opinion, for 
thoracentesis, for both sero-fibrinous and purulent exudations. I greatly 
prefer the use of the exhausting-bottle rather than the exhausting-pump 
without the bottle, as it is more convenient and produces greater suc- 
tion, from its greater size. The canula is provided with an arm, which 
connects it by tubing with the exhausting-bottle. Beyond this arm, 
the body of the canula, sufficiently expanded to contain India-rubber 
packing, extends about one and one-half inches, and is provided with a 
stopcock. Through this packing the trocar is introduced, and, after 
the puncture, it is withdrawn to the stopcock, which is then turned to 
prevent the admission of air. Then the obturator is introduced in place 
of the trocar, so as to remove any obstruction which may enter the 
canula. 

The tubing which extends from the arm of the canula to the bottle 
should be firm, with a somewhat larger bore than that of the canula, 
and its point of attachment to the bottle should also be provided with a 
stopcock. A short glass tube introduced into this tubing near the 
canula is convenient for noticing the character of the fluid, which, if it 
be thick pus, may flow w T ith difficulty, and not reach the bottle. A 
bottle of sufficient capacity to hold two quarts obviously produces more 
suction power than one of less size, and is, therefore, preferable for cer- 
tain cases, and its sides should be marked to indicate ounces and drachms. 
The tube which connects the canula with the bottle enters through the 
stopple, and proceeding from the stopple is another tube similar to the 
first, to which the syringe is attached. The syringe has two points for 
attachment to the tube, and a double action in its interior, so that at- 
tached by one point it exhausts the air from the bottle, and attached by 
the other point it condenses air in the bottle. The stopcock between 
the canula and the bottle should always be closed when the syringe is 
used, whether for exhaustion or condensing. It is very important that 
this should be constantly borne in mind when working the syringe, or 
air may be thrown into the pleural cavity and much harm done. 

Mode of Operating for Sero-fibrinous Exudations. — In the following 



TREATMENT. 653 

remarks I shall state what I consider the best method for performing 
thoracentesis, having formed my opinion from the cases which I have 
witnessed and been able to follow, in institutions and in family prac- 
tice. A mode of treatment which may be safe and proper for the adult 
is not always the best for the child, and, as there are different opinions 
and different modes of procedure, and as many who are familiar with 
adult cases recommend similar treatment for the child to that which 
they have employed with success for the older and more robust cases, I 
shall advise the abandonment of certain measures which are in common 
use, and the substitution of others. The hypodermic syringe should be 
first introduced at the point where it is proposed to perform the opera- 
tion, the needle being inserted about one inch, for I hold it unjustifiable 
to tap the chest without first ascertaining that there are no adhesions at 
the site selected for puncture, and at the same time ascertaining the 
character of the liquid. Incision of the skin with the knife and spray- 
ing the surface with ether are not required as preliminary treatment, 
since the puncture is quickly and easily performed with a small trocar, 
and with very little pain. The rule is established by many observa- 
tions that the operation should be performed in or near the vertical line 
passing through the angle of the scapula, and between the eighth or 
ninth ribs, or one of the adjacent intercostal spaces. I have elsewhere 
stated that a point a little external to this line is preferable, as the lung- 
is less liable to be injured. The instrument should obviously be inserted 
no farther than will be sufficient to reach the liquid, and, since from 
measurements which I have made, the thickness of the thoracic wall in 
rather fleshy children is about half an inch, penetration to the depth of 
one inch will ordinarily be sufficient to pass the fibrinous layer. We 
are liable to puncture more deeply than is necessary without some safe- 
guard, and incur the risk of wounding the lung. India-rubber tubing 
may cover the instrument to within one inch of the end, or a cord may 
be tied snugly around the instrument at one inch from the tip. The 
sensation communicated to the fingers will, however, be the best guide 
to the careful operator as regards the exact depth to which the instru- 
ment should be carried. The trocar should now be withdrawn, the ob- 
turator introduced in its place, the air exhausted from the bottle, and 
then the stopcock turned, to allow the liquid to escape. 

It should flow slowly, as it probably will, through so small a canula, 
but the flow can be regulated by the stopcock. The quantity to be re- 
moved depends upon the age and condition of the child, the size of the 
cavity, and the quantity of the liquid, but if the patient begin to cough 
or feel uncomfortable after the removal of one-half, or even one-third of 
the liquid, the canula should be withdrawn. The sensation of insuffi- 
cient breath is no longer experienced, and the remaining liquid is pro- 
gressively absorbed. This operation is one of the easiest in surgery, 
while, with the precautions mentioned above, no ill effect need be ap- 
prehended. One operation is, in most instances, all that is required, 
though, if need be, it can be repeated after some clays, and it is very 
seldom that the lung does not fully expand to fill the chest if the opera- 
tion be performed at the proper time. 

Mode of Operating for Empyema. — It will aid in understanding this 



6o4: PLEURITIS. 

part of our subject to remember that all pleuritic exudations contain 
pus-cells, and that the only anatomical difference between sero-fibrinous 
exudations and empyema is in the proportion of these cells. There is, 
therefore, no fixed and definite boundary line between the two kinds of 
exudation. The term empyema is, as all know, applied by common 
usage to the liquid when it contains so many leucocytes or pus-cells that 
a turbid appearance is imparted to it. Absorption is slow and difficult, 
or impossible, if the liquid contain a large amount of solid ingredients, 
to wit, fibrin and pus-cells, while liquid containing only a small pro- 
portion of these constituents more readily enters the absorbents. In 
other words, thin pus may be absorbed and removed from the system 
by natural methods, or by the same instrument and operation which we 
have recommended for sero-fibrinous exudations, while a thick liquid ad- 
herent to the pleura, or sinking heavily in dependent portions of the 
cavity, disappears very slowly, losing by absorption only a little of the 
liquor puris, while the bulk of it cannot be absorbed, so that the only 
relief is by evacuation through an opening. Often in practice, after the 
acute symptoms of an empyema have in a measure abated, the physical 
signs indicate some diminution of the liquid in successive weeks, but 
further removal soon comes to a standstill, and the resources of surgery 
must be tried. 

The same small trocar and canula, or a little larger, should be used for 
tapping the chest of an empyemic child which we have recommended 
for sero-fibrinous exudation, and with the same precautions. If the 
liquid be thin and but slightly turbid, if it be but little removed from 
sero-fibrin in its character, it will flow through the canula, even if it be 
necessary to use the obturator often to remove obstructions. Having 
withdrawn all the liquid which will flow through the opening, unless 
severe coughing or some unpleasant symptom occur, which is an indica- 
tion to discontinue the withdrawal, the instrument is removed, and the 
aperture may be closed with adhesive plaster. In exceptional instances 
one operation is sufficient to effect a cure, though convalescence in em- 
pyema is tardy under the most favorable circumstances. If we observe 
from week to week some return of appetite, more cheerfulness and sleep, 
easier breathing, and less frequent cough, the case can be left to hygienic 
management and restorative medicines. If, as is probable, the improve- 
ment be only temporary, and after some days examination show that 
the liquid has reaccumulated to nearly or quite its former quantity, and 
symptoms occur which indicate the need of surgical interference, the 
operation should be repeated. The use of a small trocar produces no 
shock or prostration, and very little more pain than occurs from the 
hypodermic injection of medicine. 

It seems to be a belief in the profession that pus in the pleural cavity 
should be evacuated as soon as discovered, without regard to the dura- 
tion of the pleurisy, or the amount of distention and pressure. But in 
cases of its early evacuation — as, for example, when the inflammation 
has continued two weeks — patients have not in my practice done so w r ell 
as when ten or twelve weeks have elapsed and the pleural surface has 
become thickened and less vascular. 

In most cases the pleural cavity refills with pus in a few weeks after 



TREATMENT. 655 

aspiration, and the operation is again required. After three or four 
aspirations, if the secretion of pus do not appear to diminish, a free 
incision should be made with the knife at the same point as that 
selected for aspiration — that is, between the eighth and ninth ribs, and 
in the line passing perpendicularly through the lower angle of the 
scapula. An incision should be made with a sharp-pointed bistoury 
a little nearer the ninth than the eighth rib, sufficiently large to admit 
the blunt-pointed bistoury, and with this the incision should be ex- 
tended to the distance of one-third to one-half inch, which will allow 
the pus to flow out freely. The opening should then be covered by 
oakum confined by long strips of adhesive plaster. Pus may or may 
not continue to flow into the oakum. If it do not the opening will 
close, if left to itself, within two or three days. No tent or drainage- 
tube is employed, for reasons to be mentioned hereafter. The physi- 
cian should return after twelve or twenty-four hours, not later, and 
should introduce through the opening the ordinary gum-elastic male 
catheter, warmed so as to be flexible, and strongly bent at its middle. 
The point should be directed to the bottom of the cavity. Perhaps the 
soft rubber catheter might be preferable, but I have never used it, being 
satisfied with the other. The catheter should be attached by tubing to 
the exhausting-syringe or bottle, and any pus in the depending portions 
of the cavity will be readily removed. I have generally, at this visit, 
removed from the bottom of the cavity two or three ounces, sometimes 
very thick, and such as would not readily flow from the opening. Every 
day or twice daily the operation should be repeated, which will, I think, 
more effectually remove the pus than washing out the cavity, and the 
opening cannot close. This operation detains the physician only a few 
moments. The catheter should be a No. X., and it is the best possible 
probe. By the close of the first week the opening becomes fistulous. 

After each removal of the pus, long strips of adhesive plaster firmly 
applied over the ribs, from the sternal region downward and backward, 
facilitate approximation of the pleural surfaces and obliteration of the 
cavity. During convalescence, the patient, if old enough, should be 
directed to make full inspirations, which serve to expand the lungs. 

That so simple and important an operation as thoracentesis should have 
been known and practised by the ancients, even, it is said, by Hippo- 
crates, and have fallen into disuse, till it was revived, in our own times, 
by Bowditch and Trousseau, seems remarkable. This was probably in 
part due to the bad instruments employed, and in part to the fact that 
in olden times the operation was performed in the anterior walls of the 
chest, where adhesions are frequently present. But there are certain 
accidents and unfavorable results of the operation which may be profit- 
ably considered, since they can nearly always be avoided. 

1st. The Admission of Air into the Pleural Cavity. — This is un- 
necessary, and can be avoided ; but those who have often witnessed the 
operation, as ordinarily performed, have remarked the fact that the ad- 
mission of more or less air is common. 

The entrance of a certain amount of air into a serous cavity, when 
the serous membrane is in its normal state, does not appear to be pro- 
ductive of harm with ordinary precautions, as regards temperature, 



656 PLEURITIS. 

etc., as in ovariotomy, in which air is admitted into the largest serous 
cavity in the body ; and the moderate admission of air into the pleural 
cavity, when the pleura is healthy, does not, as a rule, produce any ill 
effect. Thus a case is related of a man who suffered from heart disease, 
and was led to think that the pressure of a small amount of air inter- 
nally might be substituted for external pressure, which always gave 
relief. 1 He was his own instrument-maker and operator. He con- 
structed a small tube about as slender as a common pin, to which a 
bladder was attached filled with air. The point of this was thrust 
through an intercostal space till it penetrated the pleural cavity, and 
air was made to enter by compressing the bladder. Relief always 
followed, and the patient's health improved. This treatment was con- 
tinued two or three years. Dr. Lizars, who was present at the meeting 
of the Medical Society before which this case was related, stated that 
he had performed a similar operation on four or five patients affected 
with aneurisms, with some apparent benefit, and in no case with injury. 

But the condition is very different if there be inflammatory products 
in the cavity. It is a fact known to all observers that animal liquids 
withdrawn from the circulation, and escaped from the vessels through 
injury or disease, remain in a closed cavity for a lengthened period 
without putrefactive change, as for example a clot of blood under the 
scalp or pericranium of a newborn infant ; but if air be admitted, it be- 
comes offensive within a few hours. The admission of air into the 
pleural cavity which contains exuded products undoubtedly promotes 
putrefactive changes in the latter, and the admission of even a small 
amount of air, containing, as it does, microorganisms, which multiply 
rapidly in the animal fluids, and which appear to be the active agents 
in putrefaction, suffices to convert sero-fibrin, or laudable pus,. into an 
offensive, irritating, and poisonous liquid, which increases the constitu- 
tional disturbance and the gravity of the disease. 

Air in the pleural cavity, in proportion to its quantity, also tends to 
prevent the approximation to each other of the pleural surfaces and the 
obliteration of the cavity, which is required in all empyemic cases, since 
it is the mode of cure. Obviously the entrance of air does less harm if 
there be a fistulous opening and pus escape as soon as it forms, than in 
a closed cavity, but it should, in all instances, be avoided, as never 
beneficial, and likely to do harm in the manner indicated. It is never 
a necessary accident of thoracentesis, since it can be avoided by the use 
of proper instruments provided with India-rubber packing and stop- 
cocks. There can be no doubt, also, that the point of the aspirator has 
often so pricked and torn the lung, that air has entered the cavity from 
this organ — a result avoided by judiciously using the trocar and canula. 

2d. The lung is sometimes injured by the point of the hypodermic 
needle, employed for diagnosis. Cases are recorded in the hospitals of 
New York, of the breaking off and loss of the needle in the lung, from 
sudden and strong movement of this organ, as in coughing. The most 
severe injury is, however, commonly produced by the aspirator needle, 
and some very serious cases of this accident have occurred, in which the 

1 London Lancet, January 15, 1831. 



TREATMENT. 657 

needle so pierced and tore the lung that not only air escaped from it, 
but also a considerable quantity of blood. It is obvious that the danger 
of injuring the lung is greater in recent than in chronic cases, and 
greater in sero-fibrinous than in purulent pleuritis, for a thickened, in- 
filtrated, and firm pleura affords protection to the lung. It is very 
difficult to avoid injuring this organ if suction be made and the liquid 
be withdrawn with the unguarded point of the aspirator needle project- 
ing into the chest. The removal of the liquid necessitates the imping- 
ing of the lung upon the point of the instrument even if it be held very 
obliquely, and in recent cases, when there is little thickening and infil- 
tration of the pleura, the surface of this organ may be pricked or torn 
sufficiently to allow air to escape, and hemorrhage occur, when the oper- 
ator who holds the needle can scarcely believe that such an accident 
were possible, so slight has been the sensation communicated to the 
fingers. Thus thoracentesis w T as performed on an infant of two months 
who had severe empyema of short duration. The instrument was held 
by myself obliquely, and it entered the pleural cavity only a short dis- 
tance, and yet the lung was injured in three places, from which it was 
probable, from the signs and symptoms, that air had escaped. The 
specimen showing the injury was exhibited to the Pathological Society 
in 1879. Obviously, to prevent this injury, aspiration should be per- 
formed through the covered needle, as that of Phelps, or Potain's, or, 
which I have recommended above, and prefer, the trocar. I must here 
repeat what has been stated above, not to plunge the trocar to a greater 
depth than is needed, which is about one inch. The end of the canula 
may also injure the lung if it be pressed in too deeply, since it is neces- 
sarily rather sharp from its small size. 

3d. Washing out the Pleural Cavity. — Since the aspirator has come 
into general use, it is the common practice to wash out the pleural 
cavity with carbolized water in the treatment of empyema. The pro- 
portion of carbolic acid to water commonly employed is about one part 
to eighty, and at a temperature of 100°. From a discussion at the 
meeting of the New York Surgical Society, Oct. 12, 1880, it appears 
that the use of carbolized water involves risk of carbolic acid poisoning 
in case the liquid be only partially removed after it is thrown into the 
pleural cavity, and the late Prof. Erskine Mason was in the habit of 
employing salic}dic acid, one part to one hundred of water, in place of 
carbolic acid, since it possesses all the advantages with none of the 
possible risks of the latter. He stated that it promptly deodorizes fetid 
pus even in the proportion of one part to two hundred. The use of car- 
bolic acid would probably be entirely safe if the liquid were removed 
immediately after washing the cavity, but for some reason this is not 
always possible. In case of an infant with empyema under treatment 
by Drs. Lockrow, Billington, and myself, after removing the pus by 
trocar and canula attached to the exhausting-bottle, and once washing 
out the pleural cavity, the liquid was thrown in a second time, §iij into 
the left pleural cavity of an infant of five months, but not a drop of it 
could be removed. There was, however, no symptom which we could 
refer to the carbolic acid. In view of these facts, and the possible 

42 



658 PLEUKITIS. 

danger of carbolic acid poisoning, the use of salicylic acid appears to be 
preferable, at least for children, who arejess able to resist the action of 
poisonous agents than adults. • 

In this connection I must state my conviction that washing out the 
pleural cavity is unnecessary if empyema be treated as recommended 
above, and it may be injurious. But it is proper treatment when the 
pus has undergone decomposition, is offensive to the smell, and therefore 
poisonous. If it be putrid, its immediate disinfection as well as removal 
from the pleural cavity appears to be clearly indicated, but in the com- 
mon form of empyema, as the pus escapes through the opening which 
has been made, and the suppurative cavity becomes smaller, adhesions 
of the pulmonary and costal surfaces occur, which the injection of water 
may tear up and destroy, and thus the obliteration of the cavity is 
retarded. Letting out the pus and approximation to each other of the 
pleural surfaces are the indications as regards surgical measures. Be- 
sides, washing out the pleural cavity is not devoid of danger. Alarming 
symptoms may be developed unexpectedly and rapidly, even when the 
operation is slowly and cautiously performed. The infant of five months, 
with empyema, whose case I have alluded to, furnished a striking ex- 
ample of this. Four ounces of pus had been removed through a small 
canula from the left pleural cavity, and without removing the canula the 
cavity had been once washed out. It was proposed to repeat the wash- 
ing, as the infant had thus far tolerated the operation, and was in an 
unusually favorable state for a case of empyema. The patient was in a 
semi-erect position, and three ounces of water at a temperature of 100° 
had entered the cavity from the inverted bottle, when he began to 
cough, fretted, and became very restless. Immediately Dr. Lockrow 
applied the suction-point of the syringe to the tubing, and attempted to 
withdraw the liquid, but with no result. The patient's face assumed a 
deadly pallor, he frothed at the mouth, his lips were compressed, and 
breathing ceased. He was to all appearances dead. He was imme- 
diately placed upon the back by Dr. Billington, and by prompt resort 
to artificial respiration, the terrible suspense was soon ended by the 
gasps of the child, and the return in a few moments of consciousness 
and normal respiration. It seemed to me that this untoward accident 
was due to the flow of water against the heart, so that it prevented full 
dilatation of its cavities, and, consequently, diminished the flow of 
blood into the aorta and produced anaemia of the brain. Lichtenstern 
says: "Various causes, which sometimes quite interrupt or impede the 
flow of blood to the left heart, such as severe paroxysms of coughing, 
vomiting, lifting heavy burdens, may give rise to a suddenly fatal 
anaemia of the left heart, and secondarily of the brain. The anaemia 
of the lungs or brain found in many cases is only of secondary impor- 
tance. It frequently happens after thoracentesis with aspiration that an 
anaemia is produced in the partially distended lung, and this may lead to 
death by asphyxia. In sudden death during, or immediately, or a short 
time after thoracentesis by aspiration, the cause is anaemia either of the 
heart or brain. In cases in which severe syncope and sudden death are 
observed during the irrigation of the pleural cavity, the cause is either 



TREATMENT. 659 

direct mechanical concussion of the easily exhausted heart, by the stream 
of water thrown in, or shock." 1 

4th. The Use of Tent and Drainage Tube in Empyema. — With due 
regard for the opinions of the experienced surgeons who employ and re- 
commend the tent and drainage tube, but whose observations have been 
largely upon adult cases of empyema, I cannot recommend their em- 
ployment for children, unless perhaps the tent for a day or two after the 
incision ; but the tent is not necessary if the catheter be daily intro- 
duced in the manner which I have advised. The drainage tube almost 
necessarily admits air during inspiration, but this is not the most serious 
objection to it. Cachectic children with poorly nourished tissues badly 
tolerate pressure upon an open wound by a hard substance. It is liable 
to cause ulceration and enlarge the opening, and continued pressure of 
the tube may cause periostitis upon the edge of the rib and necrosis. 
Scrofulous and feeble children are very prone to both caries and necrosis 
from even slight pressure or bruises upon the surface of the bone — a re- 
sult to which adults are much less liable. In a paper published by Mr. 
TV. Thomas, 2 on the treatment of empyema by resection of one or more 
ribs, nine cases are detailed, in three of which necrosis had occurred 
from pressure, it is stated, of drainage tubes, thus necessitating the 
removal of the diseased portion. During the year 1881, a wasted 
empyemic infant was brought to one of the institutions of this city for 
treatment. After letting out the pus, a drainage tube was introduced 
and secured. At the next visit ulceration had so enlarged the opening 

that a large amount of air entered the chest with a whistling noise at 

. . . . 

each inspiration, and was expelled during expiration, and necrosis of the 

portion of the rib against which the tube pressed had also occurred. 
Air was finally excluded by covering the opening with a cloth smeared 
on each side with a concentrated solution of gutta-percha in chloroform, 
but the case after some days ended fatally. The escape of the drainage 
tube into the pleural cavity, which has occurred by breaking of the 
threads which secured it, is so rare an accident that it does not consti- 
tute an objection to the introduction of the tube; but aspiration daily or 
twice daily through the catheter so completely removes the pus that 
drainage is not required, and the risk of injury by the pressure of the 
tube is therefore avoided. 

oth. I have witnessed, in a few instances, the burrowing of pus under 
the skin at the point where an incision had been made to let out the 
pus. This complication may lead to more or less ulceration or slough- 
ing, and it greatly increases the danger of poisoning. But infiltration 
of pus will almost never occur if the incision be direct through the 
tissues and not with the skin pushed to one side, so 'that it forms a cover- 
ing or valve when it returns, as was once recommended in the books as 
a means of excluding air. But air does not enter the cavity through a 
direct opening if it be properly covered after the pus has escaped. 
Burrowing of pus and pysemic poisoning therefrom cannot then be re- 

1 Deuteches Archiv fur Klin. Med., Band I\ T ., 4 Heft. London Med. Eecord, 
Dec. 15, 1880. 

2 Birmingham Med. Bee, 1880, 1ST. S., vol. iii. 



660 NERVOUS COUGH. 

garded as an accident of the mode of operation which I have recom- 
mended. 

Exsection of a Portion of one or more Ribs. — This operation has 
now been performed a considerable number of times in Europe and in 
this country, and, from the published accounts, certain cases have ap- 
parently recovered more rapidly in consequence. Thus in one case a 
fistulous opening, spontaneously established, had continued several 
months, with little diminution in the discharge, and very slow progress 
toward recovery, when by this operation, which produced a larger open- 
ing and a freer escape of pus and falling in of the chest-wall, so as to 
obliterate the cavity, the patient rapidly convalesced. 

The alleged benefit from the exsection, which consists in the removal 
of an inch or a little more of one or more ribs, in or near the site for the 
usual performance of thoracentesis, is, that there is a readier escape of 
pus and the facility for washing out the pleural cavity is increased, and 
the thoracic wall and lung more readily approximated so as to produce 
obliteration of the pleural cavity. The greatest benefit is claimed for 
it in those cases in which the intercostal spaces are small and the ribs 
lie close to each other. 

Without denying that certain cases have apparently been benefited 
by the operation, I must say that I have not yet met a case either in 
Family or hospital practice, in which I could conscientiously recommend 
the operation, except where necrosis had occurred from a periostitis 
produced by the irritating property of the pus, or the pressure of a 
drainage tube. The gum-elastic catheter, introduced as recommended 
above, will pass through any intercostal space which I have yet ob- 
served, so as to allow free evacuation of the pus by suction, if it be not 
incapsulated by fibrinous bands, and allow also the free washing out of 
the pleural cavity if this be desired. 

There are also serious objections to the exsection in case of a child. 
The system, exhausted by supj3urative inflammation, is in poor con- 
dition to tolerate an operation of any severity, and although we are 
directed to preserve as far as possible the periosteum from injury by the 
knife, and be careful not to wound the intercostal vessels, there are 
necessarily more or less shock and hemorrhage and consequent danger 
of hastening the death of the patient. In one of the cases, that of an 
infant, reported by an advocate of the operation, it seems to me that 
death was largely attributable to the exsection. 

In order that exsection aid materially in the approximation of the 
lung and ribs, it is necessary to remove portions of two or more ribs, 
and the greater the operation the greater the risk. But what is needed 
is not depression of the ribs, which may produce permanent deformity, 
but expansion of the lung, and this is promoted by the integrity and 
resiliency of the ribs. 

Nervous Cough. 

A nervous cough sometimes occurs in children, especially between the 
ages of two or three and ten years. It may result from disease of the 
brain, from the second as well as first dentition, from some irritant in 



TREATMENT. 661 

the intestines, as worms, and also from spinal irritation. Occasionally 
there appears to be no local cause, but a state of ansemia, or a highly 
developed nervous temperament, to which it seems proper to ascribe the 
cough. Occurring under these last circumstances it corresponds with, 
and is sometimas accompanied by, functional disturbance in the action 
of the heart, as palpitation. 

A nervous cough is short, painless, and without expectoration. It 
usually attracts little attention at first, but from its long duration the 
friends finally become anxious lest it betoken some serious disease. At 
times it may nearly subside if the patient lead a quiet life and the gen- 
eral health improve, and there are periods of recrudescence if the oppo- 
site conditions obtain. It may have a spasmodic character, especially 
in times of mental excitement, but in a less degree than the cough of 
pertussis. If not properly treated, it usually continues several weeks 
or months, disappearing as the general health and the tone of the 
nervous system improve. It is not in itself a serious disease, nor does 
it lead to any ailment or produce any injury of the respiratory organs, 
but it is an unpleasant malady, and is liable to be mistaken for incipient 
tuberculosis if it occur in one decidedly cachectic, and belonging to a 
family predisposed to phthisis. 

Treatment. — If there be a local cause of the cough, measures calcu- 
lated to remove this, or at least to palliate its effects, are obviously re- 
quired. Especially should constipation, or any abnormality in the 
digestive function, be corrected. But in many cases there is no ap- 
parent local ailment which produces the cough by its irritative action, 
and the remedial measures must then be twofold, to wit, measures 
designed to improve the general state, and, secondly, measures designed 
to relieve the cough. Such measures are also required in most cases in 
which there is a local cause, provided that the cough do not cease when 
treatment calculated to remove this cause has been employed. 

For constitutional treatment no remedy is so useful in ordinary cases 
as iron. The following example shows the benefit which may result 
from the use of this agent, since in this case it effected a cure without 
the aid of other measures. B — , aged 11 years, pallid and of spare 
habit, but active, and with good appetite, had been treated for this 
malady by different physicians but without improvement. His mother 
had died of tuberculosis, and some at least of the physicians believed 
that he was in the commencement of the same disease. Finally he was 
placed under the care of the late Dr. Cammann, who, detecting the 
nature of the malady, wrote the following prescription : 

R. — Ferri. subsulphat. ...... gss. 

Acid, nitric. . . . . . . . fzss. 

Aq. destillat. . . f^ 3 - — Misce. 

Dose, three drops four times daily in sweetened water. 

The cough disappeared in a surprisingly short time. If the appetite 
be poor, the vegetable tonics are required in combination with iron. 

If the cough be frequent and troublesome, medicines which exert a 
direct controlling effect upon it are required in addition to the medicines 
and measures employed to improve the general state. For this purpose 



(j&2 NERVOUS COUGH. 

no remedy is so useful as the bromides, employed alone or in combination 
with belladonna. If there be no decided anaemia, and no local cause of 
the cough, the bromides and belladonna usually effect a cure without the 
employment of constitutional measures, or if the case seem to require 
iron it may be given in the interval. The following is the prescription 
for a child of three years : 

I£. — Tinct. belladonna? gtt. xxxij. 

Potas. bromid. 

Ammon. bromid. . . . . . . . 3,azj. 

Syr. simplic. 5ji'j. — Misce. 

Dose, one teaspoonful twice daily. 

In 1871 I was asked to prescribe for a German boy, aged 8J years, 
who had a cough of this kind of two months' duration, which latterly 
had been frequent and annoying. Within a week he was entirely re- 
lieved without other remedy, by the employment of tincture of bella- 
donna, drops v, and bromide of ammonium, gr. v, twice daily. Out- 
door exercise, or country residence, and other regimenal measures 
which improve the general health, are useful in ordinary cases. 



SECTION III. 

DISEASES OF THE DIGESTIVE APPAKATUS. 



CHAPTEK I. 

ULCEEOUS STOMATITIS, FOLLICULAK 
STOMATITIS. 

Diseases of the digestive system are very frequent in infancy and 
childhood. They are for the most part readily recognized, and are 
more easily and quickly controlled by therapeutic agents, if rightly 
applied, than are the diseases of any other system. If misunderstood 
and improperly treated, they may, even when mild and very manage- 
able in their commencement, become chronic and obstinate, or even 
fatal, or they may lead to other and more dangerous diseases. It is 
necessary, then, that the physician should understand thoroughly the 
pathology as well as therapeutics of the digestive system, that he may 
make timely and correct use of the required remedies. 

The diseases of the buccal cavity in early life are for the most part 
inflammatory. The mildest is that known as 



Simple or Catarrhal Stomatitis. 

This form of catarrh occurs usually before the completion of first 
dentition, and it is most frequent under the age of one year. Giving 
rise in itself to no severe symptoms, and often being connected with 
other grave and dangerous maladies, it is, doubtless, in many cases 
overlooked. It is sometimes confined to a portion of the buccal sur- 
face, or is more intense in one part than in another. In other cases 
the catarrh is uniform, or nearly so, affecting the entire cavity of the 
mouth. 

Causes. — The common cause of simple stomatitis in infants is the 
same as that of most cases of gastro-intestinal inflammation at that age. 
This is the use of indigestible and therefore irritating food, uncleanli- 
ness, personal and domiciliary ; in fine, all those agencies which impair 
the general health, and enfeeble the digestive organs. Therefore, 
stomatitis, like entero-colitis, is more common in the city than in the 
country, and among the city poor than those in the better walks of life. 
Infants deprived of the mother's milk, and given a diet which, with all 
care of preparation, is a poor substitute for the natural ailment, are 

(663) 



6(3-1 SIMPLE STOMATITIS. 

very liable to this disease. Beaumont ascertained from his experiments 
on St. Martin that irritative changes produced in the stomach by indi- 
gestible substances were soon followed by similar changes in the buccal 
mucous membrane. Since in young infants any kind of artificial food 
is less digestible than breast milk, it is evident why those who are 
prematurely weaned or are carelessly fed are so liable to stomatitis. 
This inflammation is also sometimes due to irritating substances taken 
in the mouth, as drinks habitually too hot or too cold. Stomatitis is 
also present in measles and scarlet fever. It then corresponds with the 
cutaneous eruption, and disappears when that subsides. 

Another cause is dentition. The gum over the advancing tooth first 
becomes inflamed, and, other causes perhaps conspiring, the inflamma- 
tion extends over more or less of the buccal surface. When due to denti- 
tion the stomatitis is more frequently partial than when it arises from a 
constitutional cause. Mercury, in whatever form introduced into the 
system, excreted from the salivary glands, and flowing over the buccal 
surface, is an occasional though nowadays rare cause. 

Symptoms — Appearances. — Stomatitis, like other mucous inflam- 
mations, is characterized by increased redness and more or less thicken- 
ing of the inflamed buccal membrane, by rapid proliferation and exfolia- 
tion of epithelial cells, and by an increased functional activity of the 
muciparous follicles. The heat of the mouth is sometimes augmented 
in an appreciable degree. The gums in severe cases are swollen and 
spongy, and bleed easily if rubbed or pressed. The tongue is usually 
covered with a light fur, and the salivary secretion is frequently aug- 
mented to such an extent as to dribble from the corners of the mouth. 
Often there is little suffering, but in other instances the patients are 
fretful, experience pain from the contact of solid food, and, if nursing, 
may even wean themselves from dread of pressure of the nipple. 

Simple stomatitis is not difficult of detection, provided that attention 
be directed to the mouth. Inspection informs us of its presence and 
extent. A favorable termination may be confidently predicted, unless 
there be a state of marked cachexia, or a grave coexisting disease. If 
circumstances are unfavorable, simple stomatitis may terminate in a 
more severe form, as the ulcerous or diphtheritic. 

Treatment. — The physician should endeavor to ascertain the cause, 
and, if possible, should remove it by appropriate medicinal or hygienic 
measures. Sometimes no special treatment is required, as in measles or 
scarlet fever. When the primary affection terminates, the stomatitis 
disappears of itself. If dentition be the cause, and there be much fever 
and fretfulness, it has been the common practice to scarify the gums, 
but this operation is not often advisable. A few doses of bromide 
of potassium relieve the fretfulness, and mucilaginous and mild astrin- 
gent lotions suffice for the catarrh. Borax is a good local remedy used 
either with honey or with glycerine and water; one part of borax to 
three of honey, or a drachm of borax to an ounce of glycerine and water. 
A weak solution of alum is also a useful topical remedy. With either 
of these agents in a favorable condition of system, and without any 
serious coexisting disease, the stomatitis is relieved. 



ULCEROUS STOMATITIS. 665 



Ulcerous Stomatitis. 

In ulcerous stomatitis, the anatomical characters are those of severe 
simple stomatitis, with the additional element which gives it the name 
by which it is designated. 

The inflammation usually begins upon the gums and extends along 
the buccal surface. Little white points soon appear upon the under 
surface of the mucous membrane, producing slight prominence of it. 
These points, which are inflammatory exudations, mainly fibrinous, 
gradually enlarge. Some unite and give rise to large irregular ulcera- 
tions ; others remain isolated, producing ulcers which are smaller and 
of more regular shape. There is, indeed, no uniformity as regards the 
size and form of the ulcers. In the folds of the buccal membrane they 
are usually elongated, while inside the lips, or where the surface is 
smooth, the circular or oval form predominates. It is a noteworthy 
fact that the exudation underlies the mucous membrane, obstructing its 
nutrient vessels, so that the ulcer which results causes destruction of the 
mucous layer, and cure is effected by cicatrization. 

Ulcerous stomatitis is usually confined to that part of the buccal sur- 
face which covers the gums, or is in their immediate vicinity, but in 
some instances it affects nearly every part of the cavity of the mouth. 

If the disease be severe, considerable swelling occurs around the 
ulcers, but the swollen part is soft and cushiony, and not very tender 
on pressure. The soft and yielding nature of the swelling serves as a 
means of diagnosis between this disease and the premonitory stage of 
gangrene, since in the latter affection the swollen part is more indu- 
rated. 

If the disease grow worse, more ulcers appear, and those already 
present grow deeper and wider, and their edges more vascular. 

If, on the other hand, there be improvement, the swelling subsides, 
the ulcers become more clean, their bases approach the level of the 
mucous membrane, and present a granulating appearance. Finally the 
mucous layer is reproduced. A considerable time after the ulcers are 
healed, the new membrane which occupies their site has a redder hue 
than the adjacent surface. 

Causes. — Ulcerous, like simple stomatitis, is most frequent in the 
families of the poor. Personal un'cleanliness, poor food, a residence in 
apartments dirty, humid, or in other respects insalubrious, favor its de- 
velopment. In fine, a cachectic condition, however produced, is a com- 
mon predisposing cause. Ulcerous stomatitis frequently occurs when 
the system is reduced or enfeebled by acute diseases, as after the essential 
fevers and thoracic and intestinal inflammations. In protracted entero- 
colitis of infants, it is sometimes severe and obstinate, and a case in 
which this complication arises usually ends unfavorably. The abuse of 
mercury is an occasional cause of this form of stomatitis, as well as of 
simple catarrh. Jaccoud states that Bergeron established the fact that 
ulcerous stomatitis is propagated among soldiers by contagion, and he 
adds " it is very probable that it is the same in infants." 



666 ULCEROUS STOMATITIS. 

Symptoms. — The symptoms in ulcerous stomatitis are more severe 
than in the simple form. There are more pain, more salivation, and 
more fretfulness. The ulcerated surface is • sometimes very tender, so 
that there is but little sleep. Drinks, unless bland and lukewarm, are 
painful, and, if the ulcers be on the lips or the front of the mouth, the 
infant nurses less eagerly than usual, and even with reluctance, some- 
times weaning itself. Occasionally the submaxillary glands are tumefied, 
hard, and tender. The breath has an offensive odor. In mild cases, in 
which the stomatitis is of limited extent, this odor may scarcely be 
noticed, but in severe cases it is almost like that exhaled from putrid 
substances. The febrile movement is usually slight. 

Prognosis. — A favorable prognosis may be given unless the patient 
be in a decidedly cachectic condition, or there be a serious coexisting 
disease, under which circumstances the case may be protracted. If 
death occur, it is due to the cachexia, or to some pathological state 
quite distinct from the stomatitis, most frequently entero-colitis. Ulcer- 
ous stomatitis, when the ulcers are small and the inflammation of limited 
extent, is of course more easily cured than when it is extensive and the 
ulcers are large. 

This disease is very liable to return, unless the general health be 
good. 

Treatment. — The physician should endeavor to ascertain the cause 
of the stomatitis, and so far as possible should remove the patient from 
its influence. It is often necessary, in order to insure speedy recovery, 
to recommend a change in regimen, especially as regards diet and clean- 
liness. If the patient live in damp, dark, and dirty apartments, the 
family should seek a better residence, and he should be taken daily in 
the open air. 

Tonic remedies are generally required. The ferruginous prepara- 
tions may be advantageously given, or the vegetable tonics, or the two 
in combination. In selecting the internal remedies we must regard the 
antecedent disease, if there be any, which the buccal inflammation com- 
plicates, and on which it depends. For that large proportion of cases 
in which there is chronic intestinal inflammation, the liquor ferri nitratis 
with tincture of Colombo administered in simple syrup will be found 
useful. For local treatment Trousseau recommends occasional applica- 
tions of nitrate of silver or muriatic acid as' a caustic, and in the inter- 
vals a wash of equal parts of borax and honey. 

The chloride of lime is also considerably used in Paris. It is recom- 
mended by Rilliet and Barthez. It is applied dry to the ulcerated sur- 
face twice daily, and in the interval the mouth is washed with simple 
water. This treatment is continued till the ulcers present a healthy ap- 
pearance and begin to cicatrize. Then a weak solution of chloride of 
lime is employed, one grain to forty-five of the vehicle. By this treat- 
ment a cure is usually effected. Bouchut prefers using chloride of lime 
with honey, one drachm to the ounce. 

But painful applications are not required. The remedy which is most 
employed in this country and in Great Britain is chlorate of potassium. 
It often acts like a specific for this as well as other forms of stomatitis. 
It may be given dissolved in water with sugar, or with one of the syrups, 



APHTHOUS STOMATITIS. 667 

to render it more palatable. The dose is about two or three grains every 
two hours. It should be allowed to run over the affected part, as it is 
believed to have a local action. 

R. — Potass, chlorat. . vp ? ~j- 

Mellis gs-. 

Aquse §ij. 

One teaspoonful every two hours. 

Of all topical remedies in common use, chlorate of potassium is prob- 
ably the most efficacious. Some physicians prefer the chlorate of 
sodium on account of its greater solubility. If this wash be too painful 
in consequence of the irritable state of the ulcers, it may be mixed with 
mucilage or be employed less frequently, and borax applied in the 
interval. 



Aphthous Stomatitis. 

Aphthous stomatitis may occur at any age, but it is most frequent in 
childhood. It is sometimes designated follicular stomatitis, but the dis- 
ease affects the contiguous mucous surface, as well as the seat of the 
follicles. At first a vascular injection is observed, and within a few 
hours a whitish exudation occurs immediately under the epithelium, and 
upon the corium, in small round or oval isolated spots. The smallest 
of these patches are not larger than a pin's head, but most of them 
have a diameter of one to two lines, and they cause slight prominence 
of the surface. In two or three days the exudation softens, and the 
epithelium which covers it is thrown off, producing an ulcer, superfi- 
cial, without induration of its edges, but sensitive to the touch. It heals 
in one to two weeks, leaving only a reddish spot or stain, which soon 
fades. Sometimes two or more aphthae unite, forming a patch, and an 
ulcer of correspondingly large size. The seat of aphthous stomatitis is 
usually the internal surface of the lips and cheeks, the gums, tongue, and 
occasionally the roof of the mouth. 

Causes. — Probably in most instances the exciting cause is some de- 
rangement of the digestive organs, which may not be appreciable. We 
sometimes observe this form of stomatitis in cases of diarrhoea. Occa- 
sionally, especially in spring and autumn, two children in a family are 
affected at the same time, or two or more in a school, so that the disease 
presents an epidemic character. Children surrounded by bad hygienic 
conditions, as in the tenement houses of cities, are more liable to this as 
well as other forms of stomatitis, than are children who live in clean, 
and airy localities, and have nutritious and wholesome diet. 

Symptoms. — The constitutional symptoms in a large proportion of 
cases of aphthae are slight. In twelve children affected with this dis- 
ease Billard found the pulse from sixty to eighty beats per minute. 

The ulcers are painful, as is indicated by the cries of the child when 
they are pressed, and its fretfulness. Solid food and even drinks, unless 
bland and unirritating, are badly tolerated. The salivary secretion is 
also augmented. 

In those rare cases in which the ulcers become confluent or gan- 



668 APHTHOUS STOMATITIS. 

grenous, the state of the patient is really serious. There is then often 
gastro-intestinal disease. The symptoms indicate prostration. The 
pulse is feeble, the countenance pallid, and the body and limbs become 
wasted. 

Diagnosis. — This is easy. The only disease with which it is liable 
to be confounded is ulcerous stomatitis. In the ulcerous form there is 
antecedent and accompanying stomatitis affecting a considerable part, 
if not the entire buccal cavity, while in the follicular form the inflam- 
mation is ordinarily confined to the immediate vicinity of the ulcers. 
The character of the ulcers serves also as a means of distinction. In 
ulcerous stomatitis there is great variety as to size and form, while in 
aphthous stomatitis there is great uniformity in both these respects. The 
small, circular ulcers are characteristic of the follicular inflammation. 
Before the ulcerative stage the circumscribed character of the eruption 
serves to distinguish this form of stomatitis from other local diseases 
affecting the cavity of the mouth. 

Prognosis. — Aphthous stomatitis usually ends favorably ; but, if 
the ulcers become concrete or gangrenous, the health is seriously af- 
fected, and a more cautious prognosis should be expressed. The un- 
healthy appearance of the mouth and the real danger are more often 
due to the depressing effect of some concomitant disease than to the 
stomatitis. 

Treatment. — In ordinary aphthous stomatitis, which is discrete and 
attended by little or no constitutional disturbance, local remedies suffice 
to cure the disease. Demulcent drinks or applications to the mouth 
should be used, as the mucilage from gum acacia, marshmallow, or 
flaxseed. Mild astringent lotions with the demulcent are also bene- 
ficial. The mel boracis is one of the best and most agreeable applica- 
tions. It may be placed in the mouth with a spoon, or applied with a 
camel-hair pencil. If there be much tenderness of the ulcers, with rest- 
lessness, a small quantity of some opiate should be added to the lotion, 
or it may be administered separately. 

With this simple treatment the ulcers generally soon heal, and the 
health of the patient is restored. If, however, the ulcers be painful, 
and not disposed to heal, or be healing tardily, they may be touched 
lightly with a pencil of nitrate of silver, or, as Barrier recommends, 
hydrochloric acid in honey of roses. This diminishes the tenderness 
and expedites the healing process. A better remedy is iodoform, two 
drachms to one ounce of ether, and applied to the ulcers by a camel- 
hair pencil. 

If, as may in rare cases occur, the ulcerations be numerous, and ac- 
companied by considerable fever, there may be symptoms indicative of 
cerebral congestion, or even premonitory of convulsions. In such cases 
laxatives and the soothing effect of one of the bromides and sometimes 
of the warm foot-bath are required. 

If there be an unhealthy appearance of the ulcers, if they gradually 
enlarge or become concrete, or gangrenous, indicating a cachectic state, 
tonics should be employed with nutritious and easily digested diet, and 
antihygienic influences should so far as possible be removed. 



THRUSH 



CHAPTER II. 

THKUSH. 

The terms thrush, sprue, and muguet, the last from the French, are 
synonymous. They are used to designate a particular form of inflam- 
mation of mucous surfaces, the peculiar feature of which is the presence 
of points or patches of a curdlike appearance on the inflamed surface. 

The usual seat of thrush is the buccal membrane, but occasionally it 
aifects the faucial, pharyngeal, or oesophageal surface. It is rare in the 
subdiaphragmatic portion of the digestive tube, but a few such cases 
have been reported by Billard and others. It never affects the mem- 
brane of the nostrils, larynx, or bronchial tubes, and it very seldom 
occurs in any other part of the alimentary canal without also being 
present in the mouth. Thrush, then, is a stomatitis, pharyngitis, or 
oesophagitis, or a gastro-enteritis with the additional element which I 
have described. 

Anatomical Characters. — The first stage of thrush is that of 
simple inflammation of the mucous surface. There next appear minute 
semi-transparent points or granules, which, increasing, soon become 
white and opaque. Some of them remain as points, while others, ex- 
tending, and perhaps coalescing with those adjoining, form patches of 
greater or less extent. The white points or patches are unequally ele- 
vated. Their central part, which was first formed, is most raised, 
while their circumference projects but little above the epithelium. 
Their highest elevation is not ordinarily more than a line above the sur- 
face. They are smaller in the pharynx and oesophagus than upon the 
buccal surface. They resemble closely, in color and consistence, por- 
tions of curdled milk, and the nurse often mistakes them for such, and 
neglects to call attention to the state of the mouth. They are readily 
detached by a little force, but are speedily reproduced. Their color in 
the first days of the sprue is white, and sometimes this color continues. 
In other cases they assume, if the disease be protracted, a yellow hue. 

Their true nature, long unknown, was finally revealed by microscopy. 
They consist in part of epithelial cells, and in part of a vegetable 
growth. This parasitic plant is in most cases the oiclium albicans. Like 
other confervse, it consists of roots, branches, and sporules. The roots 
are transparent, and they penetrate the epithelial layer, sometimes even 
to the basement membrane. The branches divide and subdivide at an 
acute angle, and under the microscope they are seen to consist of elon- 
gated cells, with one or two nuclei. Around these branches are 
numerous sporules. In two or three instances I have examined the 
product of thrush removed from the oesophagus, and in both the para- 
sitic plant was the penicillium glaucum, or a conferva closely resem- 
bling it. 

In the mildest form of thrush, this morbid product is in points or 



670 THRUSH. 

small patches. If the patches be of large extent, especially if, as rarely 
happens, a considerable part of the buccal surface be covered by them, 
there is generally a state of great prostration and danger, from some 
antecedent or concomitant disease. Thrush is, indeed, often the sequel 
of some grave affection, as pneumonitis or gastro-intestinal inflamma- 
tion. Its complication with the last-named disease is common in young, 
ill-fed infants, especially those deprived of the breast-milk, and such 
cases are frequently fatal. 

Hence, some writers who have observed infantile diseases in foundling 
hospitals, regard thrush as one of the most serious maladies of early life. 
Valleix, in a book of seven hundred pages relating to diseases of chil- 
dren, devotes more than one-third to the consideration of muguet. Of 
twenty-four cases, the records of which he publishes, twenty-two died, 
but their death was due to gastro-intestinal inflammation, which the 
author considered a part of the more general disease, muguet. Doubt- 
less the same cause which produced the stomatitis, with the confervoid 
growth, in these infants, also produced the fatal gastritis or gastroente- 
ritis, occurring without this growth. Nevertheless it seems better to 
restrict the term sprue, thrush, or muguet to those inflammations of 
mucous surfaces which are accompanied by the parasitic growth. I 
omit, then, from my description of the anatomical characters of thrush, 
those subdiaphragmatic phlegmasias which some writers consider an 
important part of severe muguet, and regard them as complications, 
unless indeed the case be one of those exceptional ones in which the 
parasite has lodged and grown upon the gastric or intestinal surface. 
This explanation seems necessary in order to understand the different 
statements of w r riters in relation, not only to the anatomical characters 
of thrush, but also in reference to its mortality. 

The frequent coexistence of thrush w r ith gastro-intestinal inflamma- 
tion, has been remarked in the hospitals of Europe, and in the Infant 
Asylum and Foundling Asylum, in this city. In the post-mortem ex- 
aminations of those who have died in these institutions, having thrush 
at the time of death or immediately prior to it, and who for the most 
part have been infants under the age of three months, I have frequently 
found evidences of inflammation in every division of the alimentary 
canal. The confervoid growth was, how r ever, seldom seen below the 
fauces, and never below the oesophagus. 

Symptoms. — The symptoms in thrush are not different in most pa- 
tients from those of simple inflammation. In the mildest cases they are 
chiefly of a local nature, such as have been already described in our 
remarks on simple stomatitis. If the inflammation be more extensive, 
especially if it affect the fauces and oesophagus, the infant becomes, 
feverish and fretful, and the inflamed surface is hot, red, and tender. 
In the worst forms of thrush this surface not only presents the ordinary 
features of severe inflammation, to wit, heat, redness, and tenderness, 
but it is sometimes deficient in the natural secretion, so as to present a 
dry or parched appearance. It is in these cases that there is often a 
more extensive inflammation than that of the buccal or oesophageal 
membrane. The subdiaphragmatic portion of the digestive tube is in- 
flamed. In this severe form of sprue, thirst, loss of appetite, restless- 



PROGNOSIS. 671 

ness, vomiting, and frequently diarrhoea occur. The countenance is 
anxious and pallid ; there is rapid emaciation, and, if the disease be not 
arrested, a state of extreme prostration soon arrives. The twenty -four 
severe cases related by Valleix, already alluded to, twenty-two of which 
were fatal, were examples of this severe form. 

Causes. — Thrush most frequently occurs in those who are constitu- 
tionally feeble, or who are enfeebled by disease or by unfavorable hygienic 
conditions. Cachexia is a cause common to thrush and most other sub- 
acute inflammations of the alimentary canal. The most obvious and 
common of the unfavorable hygienic conditions alluded to is the con- 
tinued use of indigestible and improper food. It is, therefore, a common 
disease among foundlings, in institutions where these unfortunates are 
received, since they not only breathe an atmosphere which is often im- 
pure, but are deprived of the mother's milk, and are so frequently given 
a diet which is a poor substitute for it. Among the destitute of the 
cities thrush is common, since with them, from necessity or choice, there 
is the greatest neglect of sanitary requirements. Exposure to humidity, 
to variations in temperature, increases the liability to the disease, though 
in less degree than defective alimentation. Billard and Valleix agree 
that thrush is more frequent in the warm months than in the cold, that 
its maximum frequency is in the months of July, August, and Septem- 
ber. Cases in the Infant Asylum and Child's Hospital of this city, 
have appeared to me to correspond in this respect with those related by 
Billard and Valleix. Various writers have mentioned the age at which 
thrush most frequently occurs as one of the predisposing causes. Un- 
complicated thrush is not common above the age of six months. Most 
cases occur under the age of three months. Infants at the age of one or 
two weeks, if in addition to lactation they are spoon-fed by nurses over- 
anxious that they should thrive, are liable to take the disease. Thrush 
is not common in children under the age of eighteen months who are 
suffering from exhausting diseases. It is then an unfavorable prognostic 
sign. 

Diagnosis. — This is easy so far as thrush in the mouth is concerned, 
for simple inspection by one familiar with the disease is all that is 
required in order to discover it. The presence of thrush in portions 
of the alimentary canal hidden from view cannot be positively ascer- 
tain ed- 

The vomiting, diarrhoea, pain or fretfulness, emaciation, and rapid 
sinking, which sometimes accompany severe forms of thrush, indicate 
gastro-intestinal inflammation, to which the attention of the practitioner 
should be chiefly directed. 

Prognosis. — The duration of thrush varies according to its intensity, 
and the favorable or unfavorable condition of the child. If it be slight 
and the health of the infant otherwise good, it may often be cured in 
two or three days. Under other circumstances it may continue as many 
weeks or even longer, before it is entirely removed. 

When thrush occurs in connection with gastro-enteritis, the mortality 
is very great. It has been already stated that in Valleix 's twenty-four 
cases twenty-two were fatal. M. Auvity estimates the mortality of such 
cases at nine in ten, and M. Godinat at two in three. 



672 THRUSH. 

Treatment. — As one of the most common causes of thrush is the 
use of indigestible or improper food, the physician should ascertain the 
nature of the infant's diet, and if it be faulty, should direct a better. 
In many cases the infant is bottle-fed. It should be given only the 
mother's milk if practicable, or that of a healthy wet-nurse. This 
change of alimentation often removes the sole cause of thrush in the 
young infant, so that it rapidly recovers. 

If artificial feeding be necessary, such diet should be advised as is 
directed in our remarks on the treatment of the diarrhceal maladies. 
There is often in thrush an excess of acids in the digestive tube, and an 
alkali is required. Trousseau recommends the addition of saccharate of 
lime to the milk. Children with this disease should also be taken from 
filthy and damp apartments, to those in which the air is pure and dry, 
and their mouths and persons should be kept clean. 

The remedy in common use in the treatment of thrush, and which is 
usually effectual, is borax. This, if applied sufficiently often to the 
affected membrane, not only destroys the parasitic growth, but prevents 
its reproduction. It is commonly employed with honey, or in a powder 
with sugar or dissolved in water. The officinal mel boracis, consisting 
of one part of borax to eight of honey, is so much used in families that 
it may be considered almost a domestic remedy. There is, however, an 
objection to using an application for the removal of thrush which con- 
tains either sugar or honey, since either substance remaining in the 
mouth would rather promote the growth of the parasite. Still, it is 
desirable to employ a wash of such consistence that it will remain a 
longer time in contact with the buccal surface than will a simple solution 
in water. I know no better vehicle for borax than glycerine, which has 
the advantage of consistence, does not undergo any chemical change, and 
has no unpleasant flavor. Borax may be used dissolved in glycerine, 
with or without some flavoring ingredient : 

R. — Sodii borat. . . cjj. 

Glycerine gij. 

Aquae £vj. — Misce. 

Borax should be used four or five times daily, and continued for a 
time after the disease has disappeared from sight, since the roots of the 
plant must be destroyed or the branches are rapidly reproduced. It 
should be applied by a camel-hair pencil, or with a soft cloth upon the 
finger, or a stick. It should be so freely used, in extensive and severe 
forms of the disease, that the infant will swallow some, since the entire 
oesophagus is liable to be affected in such cases. In the intervals between 
the applications of borax, if the buccal surface be hot, dry, and tender, 
so as to increase the fretfulness of the infant, it is well to use mucilagi- 
nous washes, as the mucilage of acacia or marshmallows. If the disease 
continue notwithstanding the use of these measures, the mouth should 
be occasionally washed with a weak solution of nitrate of silver or sul- 
phate of zinc: 

R. — Zinci sulph gr. ij-iv. 

Aq. rosse ^ij — Misce. 



GANGRENE OF THE MOUTH. 673 

In many cases, however, the treatment of thrush is of less importance 
than that of the disease which thrush complicates. The remedial meas- 
ures which I have mentioned then become subordinate to those employed 
for the graver disease. When this disease is relieved and the general 
health improves, thrush is more easily and permanently cured than 
during the state of feebleness and ill-health. 



CHAPTEE III. 

GANGKENE OF THE 3IOUTH. 

The diseases of the mouth which we have been considering are 
attended by little danger, but the one which we are next to consider 
is among the most fatal of early life. It is gangrene of a portion of 
the cheek or gums, or of both. It is described by writers under 
various names, as cancrum oris, noma, necrosis infantilis, aqueous 
cancer of infants. 

Anatomical Characters. — G-angrene of the mouth is sometimes 
preceded by ulceration of the mucous membrane, at the point where it 
is about to commence, but in other cases this membrane is entire. The 
tissues at the point of attack, which is most frequently the inside of the 
cheek, become inflamed, thickened, and indurated. The induration 
extends, and soon the purple hue of gangrene appears and increases. 
The next stage in the progress of gangrene is sloughing of the portion 
the vitality of which is lost. 

The slough does not present the appearance of uniform decay- 
While the color is generally dark, there are in the mass fibres of con. 
nective tissue, or even bloodvessels which remain unchanged or are but 
partially decomposed. After separation or sloughing of the part where 
the vitality is first lost, the surface of the excavation, if the disease be 
not checked, has a dark, jagged, and unhealthy appearance. Commenc- 
ing with the mucous membrane and the tissue immediately underlying 
it, the disease extends on the one side toward the skin, and on the 
other toward the deeper seated structures of the jaw. According to 
Billard, the swelling which precedes and surrounds the gangrene is in 
great part oedematous. 

This disease is occasionally primary, but in a large proportion of 
cases it is secondary. Occurring secondarily, its symptoms are often 
masked by those of the antecedent and coexisting affection. Under 
such circumstances attention is sometimes first directed to the mouth, 
by the loosening of one or more of the teeth, or the appearance on the 
skin of a livid circular spot, which indicates the approach of the disease 
to the cutaneous surface. The mucous membrane presents a dark red 

43 



67-i GANGRENE OF THE MOUTH. 

appearance for the distance of a few lines beyond the point of gangrene. 
It covers tissues which are inflamed and indurated and about to become 
gangrenous. 

The tongue is usually more or less swollen, unless the disease be 
mild ; an offensive odor arises from the gangrene, due to the evolution 
of sulphuretted hydrogen and other gases. There is great difference in 
the extent of the destruction, and the gravity of the disease, in different 
cases. It may sometimes be arrested by proper applications and a 
favorable change in the general health of the child at an early period, 
when there is little loss of substance. In other cases it extends till it 
perforates the cheek, or even destroys a considerable part of the side of 
the face, and, extending inward, attacks the periosteum of the maxil- 
lary bone, destroying the gum and teeth, and denuding the alveoli. 
Recovery, if it take place at all under such circumstances, is with the 
loss of a portion of the bone, and with deformity. 

The duct of Steno is sometimes included in the gangrenous portion, 
but it commonly resists the destructive process, and remains pervious. 

Age. — The age at which gangrene of the mouth occurs is usually 
between two and six years. In twenty-nine cases collated by Rilliet 
and Barthez, twenty-one were between the ages of two and six years, 
and the remaining eight between six and twelve years. Of the cases 
which have fallen under my observation, most were between the ages of 
two and six years. It is seen that the period of greatest frequency of 
gangrene of the mouth is different from that in which the ordinary 
forms of stomatitis occur. 

Gangrene of the mouth may, however, occur under the age of one 
year. Billard reported three cases under the age of one month, but in 
two of these the disease does not appear to have been sufficiently marked 
to render it certain that they were genuine cases. 

Causes. — Gangrene of the mouth usually occurs in those whose sys- 
tems are reduced or cachectic. It is, therefore, more frequent among 
the poor than those in comfortable circumstances ; in the city than in 
the country. It is more frequently observed in asylums for children 
than in private practice. Most of the cases which I have seen have 
been in these institutions. If the constitution be good, it can only 
occur in those long deprived of pure air and wholesome nutriment, or 
those enfeebled by disease. 

Among the diseases which have been known to terminate in or be 
followed by gangrene of the mouth, are the pulmonary and intestinal 
inflammations, hooping cough, and the fevers, both eruptive and the 
non-eruptive. Rilliet and Barthez have published a table of ninety- 
eight cases in which gangrene resulted from various diseases. In forty- 
nine of these the antecedent disease was measles, in five scarlet fever, 
six hooping cough, nine intermittent fever, nine typhoid fever, seven 
mercurial salivation, and five enteritis. It is seen that the essential 
fevers were the most frequent cause of the gangrene. Of forty-six 
cases collected by MM. Bouley and Caillault, the antecedent disease 
was measles in ali but five. In this city, also, a larger number result 
from measles than from any other disease. 

One reason why so many cases of gangrene occur as a sequel of measles 



SYMPTOMS. 



675 



is probably because this disease is accompanied by stomatitis. Simple 
or ulcerous stomatitis often ])recedes gangrene. 

Diseases sometimes terminate in gangrene of the mouth in conse- 
quence of injudicious treatment, which has lowered the vitality of the 
system. Rilliet and Barthez mention the case of a child four years 
old, in whom gangrene commenced at the twenty -ninth day of primitive 
pneumonia. This child had been reduced by the application of twelve 
leeches, three scarifications, a large blister, and by the use of absolute diet. 

The misuse of mercury was once a much more frequent cause of 
gangrene, than at present, at least in this country, since this agent was 
formerly much more employed than now. In fact most of the affec- 
tions of infancy and childhood in which mercurials were formerly em- 
ployed are now treated without it. 

Symptoms. — Gangrene of the mouth so often occurs in connection 
with other diseases, that its symptoms are in a large proportion of cases 
blended with those which arise from a distinct pathological state. 



Fig. 3; 




There is usually prostration more and more pronounced as the gan- 
grene extends. The features are ordinarily pallid, but occasionally their 
normal color is preserved for a time ; the expression of the face is melan- 
choly, but composed. Sometimes the child is fretful, if disturbed ; at 
other times it will quietly consent to an examination. The suffering is 
not proportionate to the gravity of the disease. There is less pain often 
than in some of the forms of stomatitis which are unattended with danger. 

As the disease advances, the body and limbs gradually waste, the eyes 
are hollow, or, if the gangrene be near the orbit, the eyelids become 
cedematous, the lips are infiltrated, and both the lips and nostrils are 



676 GANGRENE OF THE MOUTH. 

often incrusted. If the cheek be perforated, alimentation is rendered 
difficult, and the appearance of the child is melancholy in the extreme. 

The tongue is usually moist ; it is occasionally swollen. The saliva 
flows from the mouth, either pure or mixed with offensive sanguinolent 
matter. Unless the disease be slight, there is the peculiar gangrenous 
odor. The appetite is sometimes poor, at other times it is preserved 
through the whole sickness. There is no vomiting, or looseness of the 
bowels, unless from a complication. The thirst is usually great, and 
the pulse is accelerated and feeble, except in mild cases. 

The skin in the commencement of gangrene is hot. When .the vital 
force is much reduced, and especially as the disease approaches a fatal 
termination, the face and limbs become cool, and the surface generally 
presents a waxen or ashy appearance. No derangement occurs of the 
respiratory system. Those cases which are attended by a cough or 
accelerated respiration are really cases of bronchitis or pneumonia co- 
existing with the gangrene. 

Diagnosis. — Gangrene of the mouth is easily diagnosticated. In 
those cases in which ulceration precedes the gangrene, it may be mis- 
taken in its first stage for that form of ulcerous stomatitis in which the 
ulcers assume an unhealthy appearance. The following are the distin- 
guishing features of the two affections : Around the ulcer w T here gan- 
grene is about to commence the tissues are greatly thickened and indu- 
rated, or cedematous, while ulcerous stomatitis begins with a submucous 
deposit of fibrin, and is attended by little thickening of the surrounding- 
parts, and little or no induration or oedema. In ulcerous stomatitis the 
skin over the seat of the disease presents its normal appearances, whereas 
in gangrene it presents a distended and shining appearance. The de- 
structive process in ulcerous stomatitis is also more limited than in gan- 
grene. Deep ulcerations do not occur, or are rare. Ulcerous stomatitis 
is more readily healed, and it leaves no eschar, contraction, or deformity. 

The differential diagnosis of gangrene of the mouth from those cases 
of follicular stomatitis in which the ulcers occupying the seat of the fol- 
licles assume a gangrenous appearance, must be made by a consideration 
of the same facts or particulars which serve to distinguish it from ulcerous 
stomatitis. 

Malignant pustule, of rare occurrence in the child, resembles this dis- 
ease in some of its features. But the pustule always begins on the skin, 
while gangrene is a disease of the mucous surface primarily. In gan- 
grene, therefore, the chief destruction is of the mucous membrane and 
of the submucous tissue, while in malignant pustule the chief destruction 
is of the skin and the subcutaneous tissue. 

Prognosis. — This depends not only on the extent of the gangrene, 
but the nature of the disease, if there be one, which gave rise to it, and 
the degree of cachexia. If it occur in connection with or as a sequel 
of one of the less debilitating diseases, and there be considerable vigor 
of system, it may often be arrested when it has destroyed only the 
mucous and subcutaneous tissues, so that no deformity results. The 
friends may congratulate themselves if the case terminate so favorably. 
In the graver cases, when the gangrene extends until it destroys the 
periosteum of the maxillary bone on the affected side, and perhaps per- 



TREATMENT. 677 

forates the cheek, if the child recover it is with the permanent loss of 
teeth, tedious separation of the necrosed bone, and a cicatrix which 
may interfere with the free use of the jaw. Death is, however, the 
more common termination of severe cases. Occasionally the gangrene 
destroys the continuity of a bloodvessel, causing abundant hemorrhage, 
and accelerating the fatal result. In most cases, however, there is little 
or no hemorrhage, in consequence of coagulation in the vessels. 

Another serious complication sometimes arises, to wit, gangrene of 
other parts, as of the external genital organs. The English editor of 
Bouchut's treatise on diseases of children relates the following interest- 
ing case, from the Transactions of the Edin. Medico- Chir. Society : 

An infant eight months old became affected with gangrene of the 
face, head, and hands. " The right ear and the entire hairy scalp were 
of an intensely black color, and on both cheeks patches existed about 
the size of a half-crown piece. The right thumb and the backs of both 
hands were similarly affected. The child was noted to have been restless 
and feverish on May 22d, and on the 23d a slightly darkened ring was 
found to have formed round the thumb, about the middle of the first 
phalanx ; in a few hours the whole thumb was gangrenous, and the 
dorsum of the hand became involved. On the ear the gangrene com- 
menced with the appearance of a fleabite, and subsequently extended 
rapidly to the scalp, assuming a remarkably regular form, and giving to 
the child the appearance of wearing a black skull-cap. The pulse was 
observed to be very feeble. . . . Death took place in twelve hours 
from the first appearance of gangrene on the thumb, the child being 
sensible and continuing to suck well, up to a few minutes before death." 

Rilliet and Barthez state that pneumonitis frequently occurs in the 
course of gangrene of the mouth. Such a complication evidently 
diminishes materially the chance of recovery. 

Whether the result be favorable or unfavorable, it is evident, from the 
nature of the disease, that the duration is very different in different cases. 
The physician's attendance may be required for a week or two or for 
several weeks. 

Treatment. — As gangrene of the mouth is eminently a disease of 
debility, all anti-hygienic influences should be removed, and the most 
nourishing diet, together with tonics, be recommended. The ferrugi- 
nous preparations or the bitter vegetables are required. 

As soon as the physician is called, he should endeavor to arrest the 
gangrene, accelerate detachment of the slough, and produce a healthy 
and granulating state of the surrounding tissues. This is best effected 
by applying a highly stimulating or even escharotic agent to the in- 
flamed surface underneath and around the gangrene. For this purpose 
a great variety of substances have been used by different physicians, 
such as acetic, sulphuric, nitric, and hydrochloric acids, nitrate of silver, 
the acid nitrate of mercury, chloride of antimony, and even the actual 
cautery. 

M. Taupin recommends, after removing a considerable part of the 
gangrenous substances with scissors or some instrument, the application 
of strong muriatic acid, and, when the slough is detached, of dry chloride 
of lime. 



678 GANGRENE OF THE MOUTH. 

Rilliet and Barthez advised the use twice daily of muriatic acid or the 
acid nitrate of mercury, applied by a brush upon and around the slough, 
followed immediately by the application of dry chloride of lime, when 
the mouth is to be thoroughly washed with water from a syringe. They 
direct in the interval frequent ablution with water. After the slough 
has separated, the escharotic is to be discontinued, and the chloride of 
lime used alone. If gangrene extend to the skin, a crucial incision is 
to be made and the escharotic applied, after which powdered cinchona 
is introduced and retained by a plaster. This treatment is to be con- 
tinued till the gangrene is arrested and the decayed portion removed. 
Barrier, Valleix, and most French writers, recommend essentially the 
same treatment, namely, the application of undiluted escharotic agents. 

A safer, less painful, and in many cases successful treatment, is that 
employed by many British and American physicians, to wit, the use 
of escharotic agents diluted, or, if applied in their full strength, such as 
are least active and penetrating. Some employ from the first topical 
treatment which is astringent and stimulating rather than escharotic, 
and they report satisfactory results. 

Dr. Gerhard believes "the best local applications are the nitrate of 
silver, if the slough be small in extent ; if much larger, the best es- 
charotic is the muriated tincture of iron, applied in the undiluted state. 
After the progress of the disease is arrested, the ulcer will improve 
rapidly under an astringent stimulant, such as the tincture of myrrh, or 
the aromatic wine of the French Pharmacopoeia." 

The local treatment recommended by Evanson and Maunsell differs 
from that advised by any of the writers from whom I have quoted. A 
knowledge of this treatment, from which I have myself seen good results, 
will be best imparted by quoting from these authors : 7 " The lotion which 
we have found by far the most successful is a solution of sulphate of 
copper as employed by Coates in the Children's Asylum. His formula 
is as follows : 

B . — Cupri sulph. 

Pulv. cinchonse . . . • 

Aquse ......... 

" This is to be applied twice a day very carefully to the full extent 
of the ulcerations and excoriations. The addition pf the cinchona is 
only useful by retaining the sulphate of copper longer in contact with 
the edges of the gums. A solution of the sulphate of zinc, 5j to an 
ounce of water, by itself or combined with tincture of myrrh, Dr. Coates 
found to be also useful in some cases." 

A moment's reflection will show us that the above treatment is pre- 
ferable, provided that it is equally effectual in arresting the gangrene, 
to the treatment by the strong acids which are in common use, and the 
efficiency of which cannot be questioned. 

The purpose in applying the acid is to establish a healthier state of 
the tissues. It cauterizes and destroys whatever soft tissue it comes in 
contact with, besides it produces a strong corrosive action on the teeth 
and bone. Therefore in gangrene affecting the jaw, there is great dan- 

1 Diseases of Children, 2d Amer. edit., page 188. 



TREATMENT. 679 

ger that it will destroy the periosteum, and consequently increase the 
necrosis. 

Dr. West, 1 who advocates the use of the acid, says: " In one of the 
cases that I saw recover, the arrest of the disease appeared to be en- 
tirely owing to this agent, though the alveolar processes of the left side 
of the lower jaw, from the first molar tooth backward, died and exfoli- 
ated, apparently from having been destroyed by the acid." No such 
result follows the use of the solution of sulphate of copper. 

In one of those severe cases in which the disease resulted from scarlet 
fever, and in which there was so much debility that an unfavorable 
prognosis was made, I succeeded in arresting the disease by the use of 
Dr. Coates's prescription. The child recovered with the loss of two 
teeth and the corresponding portion of the maxillary bone. From the 
good effects which I have observed from iodoform, as an application for 
gangrenous vulvitis following measles, it has occurred to me that it may 
also be useful in gangrene of the mouth. 

If after employing the milder treatment for two or three days, the 
gangrene continue to spread, the strong muriatic acid should be cau- 
tiously applied by a camel-hair pencil or small swab, in such a way that 
it comes in contact only with the diseased surface. Its use should be 
immediately followed by an alkaline wash, as a solution of sodium 
bicarbonate. 

In 1881, an epidemic of measles occurred in the New York Found- 
ling Asylum during the attendance of Drs. O'Dwyer and Lee. The 
number of children affected with it was 165, and since many of them 
were cachectic, we were not surprised that gangrene appeared as a com- 
plication or sequel in seven cases. In a girl of 3J years, it appeared 
upon the upper jaw at the base of the teeth; in two girls of four years it 
appeared upon the inside of the cheek and upon the vulva, and not upon 
the gums; in a boy of three years it attacked the lower jaw, destroying 
four teeth with their sockets, and the upper jaw, destroying five teeth, 
with the corresponding portion of the maxillary bone, so that all the in- 
cisors and one canine were lost, as well as the cartilaginous portion of 
the nasal septum. Gangrene also occurred in the groin in this case. 
Another boy of 3 J years lost two incisors from gangrene of the jaw. 
The treatment by muriatic acid was employed, and according to the 
house physician, Dr. Kortright, there was no further extension of the 
gangrene after the first application in any of the cases. All lived ex- 
cept the first, who had broncho-pneumonia. The remaining two patients, 
aged respectively four years, died of diphtheria and pneumonia before 
treatment could be tested. One of them had commencing gangrene of 
the lower jaw, the other of the soft palate. Recently, in the Foundling 
Asylum, carbolic acid has been used as an escharotic in one or two 
cases, instead of the strong acid, and with such a result as to encourage 
its further use. 

The gases arising from the gangrenous mass are not only highly of- 
fensive to others, but they are doubtless injurious to the patient, who is 
constantly inhaling them. To remove the fetor, chlorine or carbolic 

1 Diseases of Children, 4th Araer. edit. 



680 DENTITION. 

acid, properly diluted, should be occasionally used between the applica- 
tions of the sulphate of copper. Labarraque's solution, one part to 
eight or ten parts of water, is an eligible form for its use. When the 
gangrene is removed, and the granulations present a healthy appearance, 
all danger is usually past and convalescence is fully established. Then 
no energetic topical treatment is required. A mild stimulating lotion, 
like the tincture of myrrh, as recommended by Dr. Gerhard, suffices, 
with the aid of tonics and nutritious diet. 



CHAPTEE IV. 

DENTITION. 

The opinion formerly entertained in the profession, and now preva- 
lent in the community, that many infantile maladies arise directly or 
indirectly from dentition, is erroneous. Still there are physicians of 
experience who believe that teething is a common cause of certain 
maladies, especially of functional derangements, even of organs remote 
from the mouth. On the other hand, equally good observers, and the 
number is increasing, almost wholly ignore the pathological results of 
dentition. They say that, as it is strictly a physiological process, it 
should, like other such processes, be excluded from the domain of pa- 
thology. 

A moment's reflection will show how important it is to understand 
the exact relation of dentition to infantile diseases. Every physician is 
called now and then to cases of serious disease, inflammatory and non- 
inflammatory, which have been allowed to run on without treatment, in 
the belief that the symptoms were the result of dentition. I have known 
acute meningitis, pneumonitis, and entero-colitis, even with medical 
attendance, to be overlooked, and the symptoms attributed to teething 
during the very time when appropriate treatment was most urgently de- 
manded. Many lives are lost from neglected entero-colitis, the friends 
believing the diarrhoea to be symptomatic of dentition, a relief to it, and 
therefore not to be treated. Such mistakes are traceable to the erroneous 
doctrine, once inculcated in the schools, and still held by many of the 
laity, that dentition is directly or indirectly a common cause of infantile 
diseases and derangements. 

I shall endeavor to point out what is really ascertained in regard to 
the pathological relations of dentition. 

The first dentition commences at the age of about six months and 
terminates at the age of two and a half years. The corresponding teeth 
of the two sides pierce the gum at about the same time. The two infe- 
rior central incisors first appear at about the age of six or seven months, 



PATHOLOGICAL RESULTS OF DENTITION. 681 

followed, in the order in which they are mentioned, by the upper cen- 
tral incisors, upper lateral incisors, lower lateral incisors, the four ante- 
rior molars, the four canines, and, lastly, the four posterior molars. 

The incisors usually appear in rapid succession, so that all are in sight 
by the age of one year. From the age of one year to eighteen months 
the anterior molars appear, and from the age of sixteen to twenty-four 
months, the canines, and from twenty-four to thirty months the posterior 
molars. This order is not always preserved. Sometimes the upper 
central incisors appear before the lower, and sometimes the lower lateral 
before the upper lateral. In rare cases there have been teeth at birth. 
I have seen but one or two infants with such premature dentition. 
Retarded dentition is much more common. Those who have rickets, or 
are feeble either constitutionally or by disease, often have no teeth till 
considerably after the usual period. In such the first incisors may not 
appear till the age of twelve months, or even later. 

Pathological Results of Dentition. — The evolution of the teeth 
is commonly attended by more or less turgescence around the dental 
bulbs. This is greater with some of the teeth than with others. Thus, 
the superior incisors cause more swelling than do their congeners of the 
inferior jaw. The turgescence, although attended by more or less con- 
gestion, is physiological w T ithin certain limits, and not a disease. 

But sometimes there is an unusual amount of swelling around the 
dental follicles ; the afflux of blood to them is greatly augmented ; they 
are the seat of such a degree of tenderness and pain that the infant is 
fretful. It carries the finger often to the mouth, indicating the seat of 
its suffering. The surface over the follicles presents greater redness 
than in ordinary dentition, and the salivary secretion is considerably 
increased. There is now actual gingivitis. 

Occasionally the inflammation affects a greater extent of the buccal 
surface than that lying directly over the follicles, so that most writers 
speak of stomatitis as one of the results of dentition. In a few cases I 
have known such a degree of inflammation over the advancing; tooth, 
that a small abscess formed, producing much pain and restlessness, till 
it was opened by the lancet. 

The pathological results of dentition which I have mentioned, though 
they may interfere more or less with nursing or feeding, are not danger- 
ous. They are easily detected. They result directly from the rapid 
growth and augmented sensibility of the dental follicles. 

There are other supposed accidents of dentition occurring in distant 
parts of the system in consequence of the relation and interdependence 
of organs which exist through the svstem of nerves. 

Some children, previously to the eruption of the teeth, are affected 
with diarrhoea, occasionally accompanied by irritability of stomach. 
Certain writers have supposed that gastro-intestinal catarrh is present in 
these cases ; others that there is simply a hypersecretion, an increased 
activity of the intestinal follicular apparatus, that it is, in other words, 
one of the forms of non-inflammatory diarrhoea. Barrier believes that 
the diarrhoea of dentition depends usually on what he calls a " subinflam- 
matory turgescence limited to the gastro-intestinal follicular apparatus." 
He believes that, in occasional cases, it is due to defective or altered inner- 



682 DENTITION. 

vation. It would then be analogous or similar to that form of diarrhoea 
which occurs in the adult from the emotions. Bouchut calls the diar- 
rhoea of dentition nervous diarrhoea. It is certain, however, that in 
most cases of diarrhoea which are attributable to dentition, there are 
other causes, such as unsuitable food, or residence in, an insalubrious 
locality. It is certain, as regards city infants, that the chief causes of 
diarrhoea during the period of dentition are strictly anti-hygienic, den- 
tition being quite subordinate as a cause, and probably ordinarily not 
operating at all as such. But when, as sometimes happens, at each 
period of dental condition, the infant is affected with diarrhoea, the 
influence of teething is apparent. Such cases enable us to see that 
teething may really sustain a causative relation to certain diseases not 
located in the buccal cavity. 

Among the more common pathological results of difficult dentition, are 
certain affections referable to the cerebro-spinal system. Eclampsia is 
one of the admitted results. Barrier attributes convulsions in the teeth- 
ing infant to excitement of the nervous system arising from the pain 
which is felt in the gums, and to a determination of blood to the dental 
apparatus, in which afflux the whole vascular system of the head par- 
ticipates. 

In most cases of convulsions occurring during the period of dental 
evolution, a careful examination discloses other causes in addition to the 
state of the gums. Difficult dentition must then be considered, not so 
frequently a direct as a cooperating or predisposing cause, producing a 
sensitive state of the nervous system, or possibly an afflux of blood to 
the head, of which Barrier speaks, and which, by an additional stimulus, 
perhaps trivial in itself, ends in convulsions. In exceptional instances 
eclampsia occurs mainly from dentition, or, if there are other causes, 
they are quite subordinate. This may happen when several teeth pene- 
trate the gum at or about the same time. Infants who are burned or 
scalded are very liable to clonic convulsions. This is, in fact, the chief 
danger as regards life from such accidents. So, the swollen and tender 
gum, if several teeth are about emerging, may affect the cerebro-spinal 
system like the burn or scald, and produce the same nervous phenomena. 
Thus, in a case already alluded to in the chapter on convulsions, five in- 
cisors pierced the gum within about two weeks, and in this period there 
were two attacks of eclampsia with an interval of a few days. The 
attacks were not severe, and the most careful examination could discover 
no other cause than the simultaneous development of so many dental 
follicles. Previously, and since, the infant has been well. 

Dentition, sometimes, though rarely, occasions also tonic convulsions. 
The following case occurred in the practice of the late Dr. A. S. Church, 
of this city, the history of which he communicated, as follows : 

Case. — " H., seven months old, was first visited April 3, 1863. The 
patient had been fretful for several days, but about daylight on the morn- 
ing of my first visit it commenced crying, and had not ceased for a moment 
at the time of my visit, 9 A. m. The bowels were somewhat constipated 
and tympanitic ; abdominal muscles very tense. The pain was supposed 
to be in the abdomen, and a brisk cathartic, to be followed by an ano- 
dyne, was ordered. Some relief followed, but, on the ensuing and for 



DIAGNOSIS. 683 

several consecutive mornings, the pain returned, each day lasting longer, 
until the child only ceased crying while under the influence of a full ano- 
dyne. The gum over the upper incisors was considerably swollen, hot, 
and dry, but the parents would not consent to have it scarified. For the 
first week there was no fever, no vomiting, and not the least indication 
that the nervous system was suffering. About the 10th the thumbs were 
noticed to be flexed during the attack of pain, and about the loth the 
flexors of the toes were contracted and the hands were turned backward 
and outward, but only while the child was aAvake. About the 20th there 
was constant contraction of the flexors of both extremities, with opisthot- 
onos, and constant rolling of the head, loss of appetite, progressive emacia- 
tion, coated tongue, and highly inflamed gums. Consent was, finally, ob- 
tained to relieve the inflamed gum, and free incisions were made, and the 
following night the child slept comfortably for three hours without opi- 
ates. In three days the gums were freely cut again, and the teeth soon 
made their appearance. All symptoms of disease had now ceased, the 
child became playful, and on 30th the patient was discharged." 

The opinion has been prevalent in the profession, that painful and 
difficult dentition is one of the chief causes of infantile paralysis, but it 
is now commonly admitted that it is only a subordinate or remote cause, 
if indeed it is proper to consider it as a cause at all. (See Art. Paralysis.) 

Some writers express the opinion that acute meningitis occasionally 
results from teething. The facts, however, that are relied upon to prove 
thi3 are uncertain. The occurrence of meningitis during dentition is 
probably in most instances a coincidence. 

Teething less frequently disturbs the respiratory system than either 
the digestive or cerebro-spinal. A cough occurs in some infants at each 
period of dental evolution. It is attended by little expectoration, but 
appears to be associated with, in at least certain cases, an inflammatory 
turgescence of the bronchial mucous membrane. 

Acceleration of pulse is often observed at the time of greatest swell- 
ing and tenderness of the gum. It subsides with the protrusion of the 
tooth. The febrile movement of dentition is irregular, sometimes pre- 
senting a remittent form, like remittent fever or the fever premonitory 
of meningitis. Eczema and certain other cutaneous diseases are common 
during dentition, but their dependence on it as a cause has not been 
demonstrated. 

Diagnosis. — The accidents of dentition which are located in the 
mouth are easily diagnosticated, except the odontalgia which writers 
describe, and which is not necessarily attended by any perceptible ana- 
tomical alteration of the gums. Those accidents which pertain to re- 
mote and concealed organs are usually detected with ease, though it is 
often difficult to determine with certainty their relation to dentition. 

When similar symptoms arise at each epoch of teething, and subside 
with the subsidence of the gingival turgescence, teething must be re- 
garded as the cause. Or, if the disease be such as is known to be 
produced occasionally by difficult teething, and if, after a careful ex- 
amination, we can discover no other cause, while the gums are swollen, 
especially over two or more advancing teeth, it is proper to refer the 
malady to dentition. 



684 DENTITION. 

It is evident that we must often be in doubt whether the disease 
we are treating be due at all to the state of the gums, or, if so, whether 
directly or indirectly, or to what extent ; but, as a rule, if any other 
cause be apparent, we may properly regard the influence of dentition as 
quite subordinate. 

Treatment. — It is obvious that remedial measures in cases of difficult 
dentition must be twofold, namely, those directed to the state of the 
gums, and those designed to relieve the derangements or diseases to 
which dentition has given rise. If there be diarrhoea, this should be 
controlled by proper remedies, so as to reduce the number of evacua- 
tions to two or three daily. It is well to state to the friends of the 
child, who believe that diarrhoea is salutary during the period of teeth- 
ing, that this number is quite sufficient, and that more frequent evacua- 
tions endanger the safety of the child. 

The nervous affections, as convulsions, require such soothing and de- 
rivative measures as are recommended in our remarks on diseases of the 
nervous system. The bromide of potassium I have found especially 
useful and safe in cases of fretfulness and nervous excitement due to 
dentition. Demulcent and soothing lotions are sometimes useful in 
cases of painful dentition, and the infant may be allowed to hold in its 
mouth an India-rubber or ivory ring, which seems to give considerable 
relief. 

Mothers often attempt to "rub through a tooth,"' as they term it, by 
means of a ring or thimble. This should be discouraged. So great 
friction cannot fail to have an injurious effect, by increasing the swelling 
and inflammation, unless the tooth have already reached the mucous 
membrane. 

We come now to a subject which has engaged the attention of many 
physicians of ample experience, and in reference to which there is still 
a difference of opinion among the highest authorities in medicine. I 
refer to scarification of the gums. 

The gum-lancet is much less frequently employed than formerly. 
It is used more by the ignorant practitioner, who is deficient in the 
ability to diagnosticate obscure diseases, than by one of intelligence, 
who can discern more clearly the true pathological state. Its use is 
more frequent in some countries, as England, under the teaching of 
great names, than in others, as France, where the highest authorities, 
as Rilliet and Barthez, discountenance it. 

It is well to bear in mind, as aiding in the elucidation of this subject, 
the remark made by Trousseau, that the tooth is not released by lancing 
the gum over the advancing crown. The gum is not rendered tense by 
pressure of the tooth, as many seem to think, for, if so, the incision 
would not remain linear, and the edges of the wound would not unite, 
as they ordinarily do, by first intention within a day or two. This 
speedy healing of the incision, unless the tooth be on the point of 
protruding, is an important fact, for it shows that the effect of the scari- 
fication can last only one or two days. The early repair of the dental 
follicle is probably conservative, so far as the development of the tooth 
is concerned. It may help us to understand how active, how powerful, 
the process of absorption is, if we reflect that the roots of the deciduous 



SECOND DENTITION. 685 

teeth are more or less absorbed by, the advancing second set, without 
much pain or suffering from the pressure. If the calcareous particles 
of the teeth are so readily absorbed, what is the foundation for the 
belief that the fleshy substance of the gum is absorbed with such diffi- 
culty ? Too much importance has evidently been attached to the sup- 
posed tension and resistance of the gum in the process of dentition. 

Follicles in the period of development are especially liable to inflam- 
mation. We see this in the follicular stomatitis and enteritis so com- 
mon when the buccal and intestinal follicles are in a state of most rapid 
growth. Does not this law in reference to the follicles hold true of 
those by which the teeth are formed, so that the period of their enlarge- 
ment and greatest activity, which corresponds with the growth and pro- 
trusion of the teeth, is also the period when they are most liable to con- 
gestion and inflammation ? It seems probable that the dental follicles 
are most liable to become inflamed, and therefore tender, from various 
causes apart from dentition, at the time of their greatest functional 
activity. 

If there be no symptoms except such as occur directly from the 
swelling and congestion of the gum, the lancet should seldom be used. 
The pathological state of the gum which would, without doubt, require 
its use, is an abscess over the tooth. As to the symptoms, which are 
general or referable to other organs, as fever and diarrhoea, the lancet 
should not be used if the symptoms can be controlled by other safe 
measures. All cooperating causes should first be removed, when in a 
large proportion of cases the patient will experience such relief that 
scarification can be deferred. 

If the state of the infant be one of immediate danger, as in eclampsia, 
and it be not quickly relieved by the ordinary remedies, scarification 
may not only be proper but required to insure safety. For in such cases 
all measures, provided that they are safe and simple, which can possibly 
give relief, should be employed without delay. But I can recall to mind 
only two accidents of dentition which would be likely to be benefited by 
scarification, namely, suppurative inflammation in the dental follicle and 
convulsions. But since the bromide of potassium and hydrate of chloral 
have come into use as nervous sedatives, and as efficient remedies for 
clonic convulsions, scarification of the gums is much less frequently re- 
quired, for even severe eclampsia commonly yields to these medicines, 
if the condition of the bowels be attended to. 



Second Dentition. 

The fact is well established, though often overlooked in practice, that 
second dentition occasionally deranges the functions of organs, and gives 
rise to pathological symptoms. Rilliet and Barthez mention particu- 
larly neuralgic pains, rebellious cough, and diarrhoea, as effects which 
they have observed. Rilliet relates the case of a girl, eleven years old, 
who had a very obstinate and protracted cough, the paroxysms lasting 
often half an hour to one hour. This cough immediately and perma- 
nently disappeared when the molars pierced the gums. 



680 SECOND DENTITION. 

Dr. James Jackson 1 says : " I haye seen persons between twenty and 
thirty years of age much affected by a wisdom tooth not yet protruded, 
and distinctly relieved by cutting the gum. But I think the most com- 
mon period of suffering from the second dentition is from the tenth to 
the thirteenth year. The most characteristic affections are wasting of 
flesh and nervous diseases. The boy loses his comeliness, and his com- 
plexion is less clear, while emaciation takes place in every part, though 
mostly, perhaps, in the face. The nervous symptoms are various, but 
the most common are a change in the temper and a loss of spirits. With 
these there is some loss of strength. The patient is unwilling to engage 
in play, and soon becomes tired when he does do it. Among the dis- 
tinct symptoms which are not uncommon, I may mention pain in the 
head and in the eyes. The headache is not commonly severe, but it is 
such as inclines the patient to keep still. The eyes are not only pain- 
ful, but are often affected with the morbid sensibility to which these 
organs are subject. I have known boys truly anxious to pursue their 
studies obliged to give them up on this account; and these, not having 
the disposition to play, will of choice pass the day with their mothers, 
and increase their troubles for the want of air and exercise. Nervous 
affections of a more severe character are sometimes manifested." 

Whether the symptoms which have been attributed to second denti- 
tion have always been due to this cause, is questionable. Practically, 
however, it matters little whether we recognize dentition as the cause, 
or assign something else. Hygienic and medicinal measures to improve 
the general health will usually suffice to relieve the patient. Elsewhere 
I have related the case of a boy, of nervous temperament, about seven 
years old, who recovered immediately from a cough which had lasted 
for several weeks, by taking a mixture of iron and nitric acid. Many 
do well without medicine, simply by hygienic measures. Dr. Jackson 
says: a The remedies which I have found most useful areas follows: 
First, a relief from study or from regular tasks, yet using books so far 
as they afford agreeable occupation or amusement. Second, exercise in 
the open air, preferring the mode most agreeable to the patient, and in 
more grave cases the removal from town to country." 

1 Letters to a Young Physician. 



CATARRHAL PHARYNGITIS. 687 



CHAP TEE Y. 

CATARRHAL PHARYNGITIS, PERI-PHARYNGEAL ABSCESS, 
(ESOPHAGrlTIS. 

Children of all ages are liable to inflammation of the pharynx. In 
its mildest form it often, doubtless, escapes detection in the young in- 
fant. In older patients it is revealed by pain in swallowing solid food, 
and more or less tumefaction below the ears, apparent to the sight. It 
is said to be less frequent in infancy than in childhood. In the adult, 
and in children over the age of four or five years, inflammation of the 
pharyngeal surface is often confined to the portion of membrane which 
covers or immediately surrounds the tonsils. It occurs in connection 
with inflammation of these glands. But in infancy and early childhood 
this limitation is comparatively rare. Catarrhal inflammation of the 
fauces at this age is ordinarily general, the tonsils participating in the 
morbid state. 

Pharyngitis is primary or secondary. The secondary form occurs in 
measles, scarlet fever, bronchitis, croup, pneumonitis, and occasionally 
in other affections. As these diseases are common, physicians are 
oftener called to treat patients who have the secondary form than the 
primary. Rilliet and Barthez met eighty-three secondary to sixteen 
primary cases. 

Anatomical Characters. — The pathological anatomy of pharyn- 
gitis is ascertained by depressing the tongue and inspecting the fauces. 
The faucial surface is seen to be redder than in health, with more or 
less swelling, according to the intensity of the inflammation. In the 
primary inflammation the color is commonly bright red, almost like that 
of arterial blood. If, on the other hand, the inflammation occur in 
connection with a constitutional malady, the hue is often darker. In 
grave cases of scarlet fever or measles it is sometimes even livid, indi- 
cating a vitiated state of the blood, a condition of real danger. The 
tonsils are tumefied so as to project, though not to the extent which we 
observe in the adult. They are then less firm than in the normal 
state. The follicles of the throat are enlarged and active, pouring out 
a muco-purulent secretion. This is sometimes seen in a layer over the 
tonsil or the posterior portion of the fauces. In a case of primary 
pharyngitis examined after death by Rilliet and Barthez, the tonsils 
were softened, infiltrated with pus, and slightly enlarged. A layer of 
bloody mucus lay on the pharyngeal surface, which was dark red, thick- 
ened, and glandular. The submaxillary glands were also swollen and 
somewhat softened. 

If the inflammation be intense, the deep-seated portions of the tonsils 
become involved, and even sometimes the adjacent connective tissue. 
In such cases, by applying the fingers in the hollows below the ears, 
the tonsils can be felt. 



688 CATARRHAL PHARYNGITIS. 

Causes. — The usual cause of primary pharyngitis is exposure to 
cold. It also occasionally occurs from the use of drinks too hot or con- 
taining some irritating substance. I have met it in the most intense 
form caused by swallowing boiling water, and, in one case, from acetic 
acid taken through mistake. When it occurs in the eruptive fevers, it 
is usually part of a more extensive phlegmasia, in which the buccal and 
perhaps laryngeal and nasal surfaces participate. 

Symptoms. — Fever, with thirst and loss of appetite, is common, and 
is usually proportionate, in intensity, to the extent and severity of the 
inflammation. At first there is dryness of the faucial surface, and this 
is succeeded by a more or less abundant viscid secretion. Swallowing 
is painful, except in mild cases. The muscles of the anterior half 
arches, which by their contraction close the opening from the pharyn- 
geal to the buccal cavity, and those of the posterior arches, which close 
the opening to the nasal cavity, both which sets lie a little under the 
mucous membrane, are often so infiltrated with serum that their con- 
tractile power is diminished, and if the same happen with the constrictor 
muscles, which carry downward the food, swallowing becomes difficult, 
and in the attempt more or less of the ingesta is liable to return into the 
mouth, or enter the nostril. During health the air passes through the 
nostrils in the pronunciation of two letters only, namely, N and M, but 
in severe pharyngitis, in consequence of the swelling, and the impair- 
ment of the action of the muscles concerned in speech, the air passes 
through the nostrils with the utterance of many words, producing the 
nasal tone of voice. Sometimes the inflammation traverses the Eus- 
tachian tube to the middle ear, causing earache, which may be relieved 
by the escape of pus down the tube, or by perforation of the drum into 
the external ear. 

The breath is foul, but not fetid ; the respiration normal, or but 
slightly accelerated ; there is commonly no cough, but it is sometimes 
present, due to the extension of the inflammation to the upper part of 
the larynx, or to the collection of mucus around the aperture of the 
glottis. In most cases of pharyngitis a light fur covers the tongue, and 
stomatitis of a mild grade is present, as shown by redness of the buccal 
surface, and increased mucous secretion. 

Chronic pharyngitis, which is so common in adults, and which is pro- 
duced in some by gastric derangements, and in 'others by excessive 
smoking, or the prolonged use of intoxicating drinks, and in others, still, 
by the syphilitic or mercurial cachexia, is comparatively rare in children. 

Prognosis. — In mild cases of pharyngitis convalescence commences 
within a week. If the inflammation be dependent on a constitutional 
malady it may continue considerably longer, especially if the glands of 
the neck, and the connective tissue, be much involved. The prognosis 
in secondary pharyngitis is less favorable than in that of the primary 
form. In fatal cases there is usually a vitiated state of the blood, either 
from the coexisting constitutional disease, or from previous cachexia. 

Pharyngitis may, however, become dangerous from complications to 
w r hich it gives rise. The proximity of the inflammation to the brain, or 
its effect upon the cerebro-spinal axis through the medium of the nerves, 
sometimes gives rise to clonic convulsions. In a recent case of primary 



TREATMENT. 689 

pharyngitis in my practice, repeated and violent convulsions occurred in 
an infant, about one year old, from this cause. They commenced at the 
inception of the inflammation, and constituted the only real danger. 
Pharyngitis may interfere materially with nutrition in consequence of 
the dysphagia, but in most cases of primary pharyngitis this symptom 
does not continue sufficiently long to endanger the life of the patient. 
In grave constitutional affections, as scarlet fever, the difficulty of swal- 
lowing, and the consequent innutrition, augment the danger. As re- 
gards, therefore, the prognosis in catarrhal pharyngitis, whether primary 
or secondary, it may be stated as a rule, that it is not, per se. a fatal 
disease, but is only so from complications, or from aggravating the 
primary malady with which it is associated. 

Diagnosis. — This is not difficult provided that attention be directed 
to the throat ; but the physician often fails to discover it at his first 
visit, from neglecting to examine this part. In many cases the local 
symptoms are not well marked, and in the absence of these the febrile 
reaction may at first be referred to some other cause than the true one. 
Inspection not only reveals the presence of inflammation, but enables us 
to determine whether it be simple pharyngitis, or diphtheritic or ulcera- 
tive. In some instances, simple pharyngitis resembles the diphtheritic, 
from the presence of confervoid growths upon the inflamed surface, 
usually the leptothrix buccalis. The differential diagnosis is based on 
the easy removal and soft pultaceous character of the confervse, and the 
appearance under the microscope. 

Treatment. — Mild cases of simple pharyngitis require little treat- 
ment. With moderate counter-irritation over the throat, and the use of 
laxative medicines, the inflammation soon subsides. The oleum cam- 
phoratum may be occasionally rubbed over the throat, and retained 
upon it by flannel. The effect is increased by the application, once or 
twice daily, of mustard or tincture of iodine, or by adding to the lini- 
ment one-fourth or one- third of its quantity of turpentine. 

Some children seem to be most relieved by a muslin compress fre- 
quently wrung out of cool water, or a light India-rubber bag containing 
ice. Frequently rubbing the neck with warm oil or camphorated oil, 
and binding upon it a rind of salt bacon, are popular modes of treat- 
ment, and no doubt are productive of benefit. 

In the severe forms of this inflammation, occurring independently of 
any other disease, more acute measures are sometimes required. 

If there be stupor or restlessness, with unusual heat of head, and 
starting or twitching of the limbs which threaten convulsions, two to five 
grains of the bromide of potassium given every two or three hours pro- 
duce a calmative effect. 

Diaphoretics and sometimes cardiac sedatives are also indicated, such 
as liquor ammonise acetatis, spiritus retheris nitrosi, ipecacuanha, and 
aconite. Medicines of this kind may be variously combined according 
to the age and condition of the patient, and the severity of the disease. 

As the symptoms abate, the intervals between the doses may be 
increased. 

In cases attended by much tenderness and dysphagia great relief is 
often obtained by hot poultices frequently applied over the neck. 

44 



690 PERI-PHARYNGEAL ABSCESS. 

Topical treatment of the pharynx is recommended by most authors. 
Rilliet and Barthez use for this purpose nitrate of silver or powdered 
alum. The former has been most employed by physicians. It may be 
applied in the proportion of ten grains to the ounce two or three times 
daily. 1 prefer the following mixture, used with the hand atomizer 
every two or four hours : 

R. — Acid, carbolic. . . . . . . gss. 

Potas. chlorat ziij. 

G-lycerinse ........ 311.]. 

Aquae gvj. — Misce. 

This can of course be used as a gargle by those old enough, or more 
continuously by the steam atomizer. 

The treatment of secondary pharyngitis will be described in connec- 
tion with the treatment of the diseases wdiich it complicates. Suffice it 
here to say that this form of inflammation must not be treated by those 
depressing remedies which may be useful in cases of idiopathic pharyn- 
gitis. 

Peri-Pharyngeal Abscess. 

Every practitioner should bear in mind the fact that an abscess occa- 
sionally forms between the pharynx and vertebral column (retro-pharyn- 
geal), or upon the side of the pharynx in the submucous connective 
tissue. This constitutes a disease which is likely to be fatal, but which 
can ordinarily be promptly relieved by the surgeon. 

Yet, if we look over the records of peri-pharyngeal abscess, we shall 
see that in a large proportion of fatal cases the disease was supposed to 
be something else, and so treated until its nature was revealed by post- 
mortem examination. The most complete monograph on this malady 
with which I am acquainted w T as published by Dr. Allen, 1 of this city, 
under the title of retro-pharyngeal abscess. To this paper I am largely 
indebted for the facts contained in this article 

Age — Cause. — This abscess may occur at any age, but it is most 
common in infancy and childhood. It is more frequent in the first two 
years of life than at any other period. Of the cases collated by Dr. 
Allen, in which the age is stated, twenty were under ten years, and 
tw r enty-one over this age. The abscess occurs in some patients from 
caries of the vertebral column, and, in others, from inflammation de- 
veloped in the connective tissue or small lymphatic glands lying imme- 
diately outside the pharynx, or from a catarrhal pharyngitis. Whichever 
the cause, there is usually a scrofulous or reduced state of system. 

Writers describe tw T o kinds of peri-pharyngeal abscess, the primary 
and secondary. This distinction is based on the fact, whether or not 
the inflammation which leads to the abscess be dependent on an ante- 
cedent pathological state. 

In the primary form the cause, is usually atmospheric, or it is some 
irritating substance which has been swallowed, and which, lodging in 
the pharynx, produces phlegmonous pharyngitis. 



ANATOMICAL CHARACTERS. 691 

The cause is mentioned in twenty cases of the primary form, collated 
by Dr. Allen, as follows : exposure to cold, ten cases ; lodgement of bone 
in pharynx, eight cases ; blow with a fencing-foil, one case. In the last 
case the button of a fencing-foil passed through the right nostril into the 
pharynx. 

The secondary form occasionally occurs after measles and scarlet 
fever. The inflammation of the pharynx, common in those diseases, 
extends to the subjacent connective tissue, and, aided by the dyscrasia 
of the patient, becomes suppurative. Such cases have been observed by 
Rilliet and Barthez. The most common cause of the secondary form is, 
however, caries occurring in the cervical vertebrae. 

When thus occurring it is similar, both as regards cause and nature, * 
to lumbar abscess. It would follow the same chronic course, and would 
properly be described in connection with it, were it not for its proximity 
to the air-passages, which renders the symptoms so urgent and dan- 
gerous. In a few recorded cases the abscess was a sequel of erysipelas. 
In nineteen cases of secondary abscess, in Dr. Allen's collection, the 
cause is assigned as follows : erysipelas of face, two ; inflammation fol- 
lowing a fall upon the inferior maxilla, one; after cerebritis, one; 
syphilis, four ; caries of the cervical vertebrae, six ; scrofula, five. 

The plausible opinion is expressed by Mr. Fleming, 1 that the sup- 
puration begins, in a large proportion of cases, in the small lymphatic 
glands which lie in the connective tissue external to the pharynx. The 
late Prof. Geo. T. Elliot 2 has recorded the case of an infant of seven 
months, in whom peri-pharyngeal abscess immediately followed, and was 
apparently due to parotiditis. 

In rare instances the abscess, or the local disease which leads to it, 
appears to exist from birth. Thus Dr. E. 0. Hocken relates 3 the 
history of an infant who died at the age of nine weeks. It had always, 
when taking the breast, thrown back its head as if nearly suffocated. 
The walls of the abscess were thick and firm, described by the writer as 
cartilaginous. Occasionally there is no apparent cause of the abscess, 
except the strumous or cachectic state. 

Anatomical Characters. — The seat of the abscess is not the same 
in all cases. The swelling can ordinarily be seen on examining the 
fauces, but occasionally it is so low as to be really peri-oesophageal, and, 
therefore, invisible. The size of the abscess varies ; sometimes it is 
large, pressing inward the wall of the pharynx even against the velum 
palati and into the posterior nares, if the abscess have a high location, 
or, if lower, against the larynx, so as to embarrass respiration. Some- 
times the abscess is so large, or has such lateral extension, that there is 
external swelling along the side of the neck. In a few cases on record 
the pus, instead of being discharged into the pharynx, made its way 
down the neck between the muscles and the connective tissue to the 
pleural cavity, which it entered, producing fatal pleuritis. 

The walls of the abscess have been found in a different state in differ- 
ent cases. Sometimes the sac, at the projecting point, is so thin that it 

1 Dublin Journ. of Med. Sci., vol. xviii. 

2 Obstet. Clinic, N/. Y., Appleton & Co., 1868. 

3 Prov. Med. and Surg. Journ., 1842. 



692 PEKI-PHARYNGEAL ABSCESS. 

seems as if there might have been a spontaneous cure, could life have 
been preserved a few hours longer. In other cases the sac is so thick 
and firm that its rupture, for many days, would be impossible. 

Symptoms. — The percursory symptoms differ in different cases, ac- 
cording to the nature of the cause, whether it be phlegmonous pharyn- 
gitis or simply adenitis or vertebral caries. If the abscess proceed from 
caries, it is preceded by deep-seated pain, greatly increased by move- 
ments of the head, and probably preceded also by induration along the 
sides of the vertebrae. 

The patient with this disease is restless, his mouth hot and dry ; tongue 
furred ; deglutition more or less difficult. Sometimes after suppuration 
has occurred there are alternations of rigors and fever. The symptoms 
indicate approximately the seat of the inflammation, but on examination 
we do not find that degree of redness of the mucous surface which we had 
been led to expect. The tissues which are chiefly involved in the inflam- 
mation, being submucous, are hidden from view. We observe redness of 
the pharynx, but it is disproportionate to the intensity of the symptoms. 
Some patients frequently experience a chilly sensation through the 
entire period of the abscess, though greater at one time than at another, 
and occasionally convulsions occur, especially in young infants. In 
ordinary cases embarrassment of respiration begins early, and is the 
cause of the chief danger. It becomes more and more marked as the 
abscess increases. It is noticed both during inspiration and expiration. 
The dysphagia also increases, sometimes to such a degree that drinks 
are taken with difficulty, and solid food refused. The respiratory 
symptoms bear considerable resemblance to those in protracted laryn- 
gitis, for which this disease has been mistaken. While the respiration 
becomes impeded or whistling, the voice is also feeble or indistinct, 
from the pressure of the tumor. 

But the symptoms described above are not all present in every case. 
They vary according to the size and location of the abscess, whether it 
be high or low, posterior or lateral. I have met the disease in a child 
old enough to make known the subjective symptoms, in whom there was 
little or no dysphagia, and others report similar cases. When the 
tumor has attained such a size as to produce well-marked symptoms and 
jeopardize the life of the patient, it, or a part of it, can ordinarily be 
seen on depressing the tongue, but usually its location and condition 
can be better ascertained by exploration with the finger. The dyspnoea 
increases as the abscess enlarges, and, after a time, unless it burst spon- 
taneously or be opened by the surgeon, imperfect oxygenation of the 
blood results. In some patients paroxysms of dyspnoea occur, so as to 
threaten immediate suffocation ; coughing or attempts to swallow induce 
these paroxysms, and the patient is forced to remain in an erect or semi- 
erect posture ; the tongue is protruded, the head thrown back, the pulse 
is frequent and rapid, the limbs become livid and cool, and finally death 
results from dyspnoea. Occasionally, when death seems inevitable, the 
abscess breaks during the struggles of the child, and the patient is 
restored to health. In rare cases the result is different. The trachea 
and bronchial tubes are deluged by the purulent discharge, and imme- 
diate suffocation occurs. The following was an example : In May, 1871, 



SYMPTOMS. 693 

a boy two years and five months old was brought to the class at Belle- 
vue, who had the symptoms of an abscess for three months. The head 
was carried on one side, its rotation caused pain, and a laryngeal rale 
accompanied respiration. The upper part of the tumor could be de- 
tected by the finger ; but, on account of its low location, it was impos- 
sible to open it with the bistoury. The temperature was 103°, pulse 
156. The case was kept under observation, but in a few days the dys- 
pnoea suddenly became so urgent that death was imminent, when the 
attending physician of the class, Dr. Swezey, broke the abscess with his 
finger, and pus was ejected on the floor; death, however, occurred 
almost immediately. 

A correct appreciation of the symptoms and nature of peripharyn- 
geal abscess will be best obtained by relating a case. I select the fol- 
lowing from the Trans, of the Land. Pathol. Soc. y Oct. 20, 1846 : 

A female infant died at the age of seven months, having had difficult 
breathing three weeks, and extreme dyspnoea during the last days of life. 
The dyspnoea was constant, and was aggravated by mental excitement, 
by movements of the body, and by exposure to cold. During the parox- 
ysms a peculiar, croupy sound accompanied inspiration. There was no 
dysphagia through the entire sickness, and death occurred from apnoea. 

The sac of the abscess was of the size of a pigeon's egg, and was situ- 
ated between the upper cervical vertebrae and the back of the pharynx. 
The abscess was flattened in front, so as not to cause any decided promi- 
nence of the wall of the pharynx. From the sac a second small cyst 
extended forward, forming a nipple-like swelling in the pharynx, which 
completely closed the orifice of the glottis. Its aperture of communica- 
tion with the body of the abscess admitted the point of the little fino-er, 
and the whole swelling was freely movable and perfectly translucent at 
its extremities and sides. The abscess might have been easily punctured, 
with probably the preservation of life. 

The duration of this malady is very different, according to the severity 
of the inflammation, the rapidity with which the abscess enlarges, and 
the direction which it points. A lateral or downward extension is not so 
immediately dangerous to life as the anterior. 

The time when the abscess begins to form cannot be precisely ascer- 
tained, and most writers, in determining its duration, compute from the 
first appearance of symptoms which are referable to the pharvnx. Dr. 
J. Byrne 1 relates a fatal case in which the disease had apparently con- 
tinued only about one week. The patient was an infant one year old, 
and its death was from apnoea. The abscess was large, extending from 
the base of the skull to the thorax, and pressing both on the larynx and 
trachea. M. Besserer 2 gives the history of an infant four months old, 
who died in the same way after thirteen days. An infant nine months 
old, whose case was published by Dr. W. C. Worthington, 3 lived nine 
days. The abscess occurred from exposure to cold; the patient was 
treated for croup, and died from suffocation. The anterior wall of the 
abscess was very thin. Since the first edition of this book was published, 

1 Amer. Journ. of Med. Sci., 1838. 

2 Archiv Gen de Med., 1840. 

3 Prov. Med. and Surg. Journ., 1842. 



69-1 PERI -PHARYNGEAL ABSCESS. 

I have met six patients with this disease in whom the pus was evacu- 
ated when the dyspnoea had become urgent. In two the symptoms in- 
dicated a continuance of the disease from two to four weeks, and in the 
third case four months. The fourth case is interesting on account of 
the short duration of the severe symptoms. The following is the record 
of it: M. E., aged 7 months, female, nursing, inmate of the New York 
Foundling Asylum, was observed to have difficult breathing for the first 
time, on March 28, 1875. Since about March 8, some swelling had 
been noticed along the side of the neck, but it gave rise to no marked 
symptoms and she had not seemed ill, till the obstruction in the respira- 
tion commenced. At my visit on the evening of the 28th, the infant 
was pointed out tome as in a dying condition. She was lying in a 
state of stupor, pallid, and gasping for breath, with a temperature of 
103°, and very feeble pulse, numbering about 200 per minute. On 
carrying the finger into the throat an abscess could be readily detected, 
situated in the walls of the pharynx on the left side posteriorly. This 
was easily opened by a curved bistoury, around which adhesive plaster 
was wound to within half an inch of the point. The breathing immedi- 
ately began to improve. On the following day the infant was playing in 
the mother's lap, with a pulse of 140, but a normal temperature. With 
the use of cod-liver oil and the syrup of the iodide of iron, its health 
was soon fully restored. In the fifth case the abscess ruptured by the 
finger, and in the sixth it was opened by the lancet. All these patients 
recovered. 

When the abscess grows slowly, and presses lightly on the air-passages, 
the case may continue for months. Such a one was observed by the late 
Professor Willard Parker. (Allin.) This infant was one year old; it 
suffered from pharyngeal symptoms nine months, was treated for tonsil- 
litis, and death occurred as usual from apnoea. The abscess was two 
inches long, and there was no disease of the vertebrae. The same sur- 
geon saved the life of another patient four years old. in whom the dis- 
ease was protracted, by puncturing the abscess ; and Professor Pbst, of 
this city, also treated successfully a case which had continued three 
months. (Allin.) 

Diagnosis. — The diagnosis of retro-pharyngeal abscess is ordinarily 
easy, provided that the physician examine carefully and bear in mind 
the occasional occurrence of such an abscess. In a large proportion, 
however, of the recorded fatal cases, the true nature of the disease was 
not recognized during life. Especially is the diagnosis difficult when 
the cerebro-spinal system is early implicated, and symptoms arise which 
divert attention from the throat to the brain. 

The maladies for which peripharyngeal abscess is most frequently 
mistaken are laryngitis and simple but severe pharyngitis. From 
laryngitis, for which it has been most frequently mistaken, it may be 
distinguished by the dysphagia and by the character of the initial symp- 
toms. In laryngitis there is usually the peculiar cough from the first 
or very early, while in abscess there is an initial period of several clays 
or even weeks before respiration is materially affected. This is the 
period of inflammation which precedes suppuration. 

In abscess pressure of the larynx backward is badly tolerated, greatly 



PROGNOSIS TREATMENT. 695 

"increasing the dyspnoea, while in pharyngitis and croup this effect is not 
so marked. In abscess the horizontal position aggravates the dyspnoea, 
but not in pharyngitis and croup. The character of the voice also aids 
in diagnosticating an abscess from laryngitis, since in the former it is 
usually nasal, and in the latter hoarse and whispering. But the decisive 
test is afforded by inspection and digital exploration. The tumor is seen, 
or, if situated too low to be seen, is felt, upon the walls of the pharynx. 

If the symptoms of abscess are masked by those arising from the 
cerebro-spinal system, as by convulsions, the priority of the pharyngeal 
symptoms aids in determining the true disease. 

In a case of suspected abscess the physician should not only carefully 
inspect the fauces, but should also employ digital examination. The 
finger will often detect fluctuation before the abscess is apparent to the 
eye. 

Prognosis. — With proper treatment the result is usually favorable, 
but, if the disease be not recognized, many die. In Dr. Allin's cases, 
of those under the age of twelve years nine died, while ten recovered by 
the opening of the abscess by the lancet, trocar, or finger, and one by 
its spontaneous rupture. 

If the abscess be due to disease of the spinal column, death may occur 
immediately after the sac is opened, the caries of the intervertebral carti- 
lages producing, according to Dr. Allin, dislocation qf the vertebras. 
Death may also occur, though rarely, from pleuritis, in consequence of 
the bursting of the abscess into the pleural cavity. Even in caries, if 
the sac be properly opened, and if need be reopened, and the head sup- 
ported by suitable apparatus, recovery is possible, as in a case treated 
by Prof. Post. 

Treatment. — The proper treatment of peri-pharyngeal abscess is 
simple, consisting in breaking or puncturing the sac by the finger, the 
lancet, bistoury, or pharyngotome. Each method has been successfully 
employed. In the majority of cases the proper way to open the abscess 
is by the ordinary curved scalpel or bistoury, which should be covered 
by a strip of adhesive plaster to within a half inch of the point. If the 
abscess be post-pharyngeal, it should be opened in the median line. A 
single incision suffices to evacuate the pus. If the abscess point or be 
elastic, there is little danger of wounding any important vessel, or pro- 
ducing dangerous hemorrhage if the operation be properly performed. 
It may be necessary to open the abscess more than once, as in a case 
reported by Dr. Post, and another which I saw with Dr. Livingston, of 
this city. In certain cases, when the knife cannot be readily employed, 
the abscess may be opened by pressure with the finger-nail or the edge 
of a teaspoon. 

Patients with this disease ordinarily require constitutional treatment, 
especially the use of tonics, ferruginous and vegetable. The citrate of 
iron and quinine, the citrate of iron and ammonium, and in strumous 
cases the syrup of the iodide of iron with cod-liver oil, are eligible pre- 
parations. Nutritious diet and often alcoholic stimulants are required. 



696 OESOPHAGITIS. 



Oesophagitis. 

Disease of the oesophagus in infancy and childhood is comparatively 
rare, inflammation being the most frequent affection of this portion of 
the digestive tube in these periods, and, indeed, the only one which 
claims attention. It is most common in infants under the age of three 
or four months, who are deprived of the breast-milk, and are given a 
diet which is with difficulty digested, and perhaps taken too hot or too 
cold. It is, therefore, most common in foundling hospitals. I have fre- 
quently observed it in the Infant's Hospital, and the Nursery and 
Child's Hospital, of this city, chiefly at the autopsies of bottle-fed 
infants under the age of six months, whose symptoms had indicated 
disease or derangement of the digestive function. Many of them had 
diarrhoea, and died in a state of emaciation. Oesophagitis in these cases 
was associated with simple or gangrenous stomatitis, thrush, or with 
gastritis or entero-colitis. Sometimes all these inflammations coexisted. 
In a few cases the confervoid growth of thrush had extended from the 
mouth to the oesophagus. It occurred in small hemispherical masses, 
scarcely as large as a pin's head. Swallowing corrosive or strongly 
irritating substances, as the acids or alkalies, is an occasional cause 
of oesophagitis, $he irritant at the same time producing stomatitis and 
gastritis. 

Anatomical Characters. — The inflamed surface sometimes presents 
a uniformly injected appearance. Usually, however, there is greater 
intensity of the inflammation in streaks or patches than over the surface 
generally. I have frequently observed at autopsies a greater degree of 
inflammation in the lower than upper half of the oesophagus, even when 
the infant had stomatitis at the time of death. 

(Esophagitis occurring from faulty regimen or anti-hygienic condi- 
tions is not accompanied by as much thickening of the walls of the tube 
as often occurs in some other portions of the digestive canal, as, for ex- 
ample, in the colon. Diphtheritic inflammation of the oesophagus is 
accompanied by so great infiltration of the mucous membrane and 
underlying connective tissue that I have seen the oesophageal walls 
three or four times the normal thickness. 

Occasionally ulcerations of the oesophageal mucous membrane are ob- 
served in the lower part of the tube, and Billard describes the ulcerative 
form of oesophagitis. At the first autopsies at which I observed these 
ulcers, I supposed that they were pathological, and indicated a severe 
grade of inflammation ; but a more extended observation has convinced 
me that they are usually post-mortem, and are not at all dependent on 
inflammation of the oesophagus. The solvent power of the gastric juice 
not only causes ulceration in the stomach, but entering the oesophagus 
may and not infrequently does produce a solvent action on the mucous 
tissue there. At the meeting of the London Pathological Society, 
March 4, 1852, Dr. Graily Hewitt presented a specimen in which the 
gastric juice had not only eaten entirely through the coats of the oesoph- 
agus an inch above the stomach, but had even attacked the left lung. 
Over the age of six months inflammation of the oesophagus is rare. 



INDIGESTION. 697 

The symptoms of oesophagitis, in young and emaciated infants, in 
whom it ordinarily occurs, are not well pronounced. Pain in deglutition, 
or tenderness on pressure over the oesophagus, if present in these infants, 
is ordinarily not appreciable, nor have they seemed to me to vomit oftener 
than other infants of this class who suffered from indigestion and gastro- 
enteritis, without oesophagitis. It is, therefore, difficult to diagnosticate 
oesophagitis in them. It is, according to my observation, oftener present 
than absent in spoon-fed infants of three months or under who have per- 
sistent stomatitis and entero-colitis. 

Treatmext. — In the oesophagitis of foundlings and ill-nourished in- 
fants, which arises, as has been stated, from faulty regimen, no treatment 
is required apart from that designed to relieve the stomatitis or entero- 
colitis with which it occurs. Attention must be directed mainly to the 
diet and hygienic management. The remedial measures proper for 
such patients are more fully detailed in our remarks on entero-colitis. 
Oesophagitis produced by swallowing corrosive or highly irritating sub- 
stances requires the same treatment as in the adult, to wit, poultices, 
demulcent drinks, etc. 



CHAPTEE VI. 

INDIGESTION, CONGESTION OF STOMACH, GASTRITIS, FOLLIC- 
ULAR GASTRITIS, DIPHTHERITIC GASTRITIS, POST-MORTEM 
DIGESTION, SOFTENING. 

Indigestiox is more common during infancy than in any other 
period of life. While the digestive organs in the adult readily assimi- 
late a great variety of food, it is necessary for the well-being of the 
infant that its diet be simple and carefully prepared. Departure from 
this rule leads to indigestion and ulterior diseases. 

After the age of two years a mixed diet is readily assimilated, the 
digestive function less frequently disordered, and indigestion presents 
few peculiarities to distinguish it from that of the adult. 

Indigestion in some children is habitual ; in others the digestive pro- 
cess is ordinarily well performed, but, from some temporary derange- 
ment of system or error of diet, an acute attack of indigestion occurs. 
Hence, two forms of this ailment may be described : first acute, refer- 
ring to temporary attacks ; secondly, chronic, referring to the habitual 
state. 

Causes. — The causes of indigestion are twofold : first, the condition 
of the digestive function independently of the aliment ; secondly, the 
unwholesome or improper character of the ingesta. Anything which 
lowers the vital powers may be a predisposing cause of indigestion, by 
impairing the function of the organs which assimilate the food. Impure 



698 INDIGESTION. 

air and personal uncleanliness f protracted hot weather, and previous dis- 
ease, are, among the common predisposing causes. The strong country 
child can thrive upon a diet which, given to the more feeble child of the 
city, would produce a deleterious results. During the summer months 
it often happens that an infant in the city cannot digest properly any 
food given to it except the mother's milk ; and from this results much of 
the infantile sickness and mortality which make this season of the year 
much dreaded by parents. There is a natural difference in children, as 
regards liability to disordered digestion. Some do well upon a diet 
which given to others similarly situated occasions vomiting, gastralgia, 
and flatulence. 

In the majority of cases of indigestion, however, the fault does not 
exist in the child. It is fed too often or irregularly, or upon a diet that 
is unwholesome or indigestible. It is well known that the milk of the 
mother or the wet-nurse is liable to changes which render it for the 
time unsuitable for the infant. Her food may be of such a quality, or 
her mind so excited, or some function of her system so disordered, as 
to effect a temporary change in the constitution of the milk. The oc- 
currence of the catamenia, or of gestation, in mothers who are suckling, 
not infrequently produces this unfavorable result. 

Indigestion is most common in those infants who, deprived of the 
mother's milk, are intrusted to wet-nurses, or fed from the bottle. The 
milk of the wet-nurse, from not agreeing with the age of the infant, 
from irregularity in her mode of life, from the acescent nature of her 
food, or from other causes which are not appreciable, may disagree with 
the infant, and be imperfectly digested. 

The most common cause of indigestion in the infant is artificial feed- 
ing. This, in the cities, is productive of a great amount of gastric and 
intestinal derangement and disease. The younger the infant, the less 
frequently does it thrive if brought up by hand. 

Whatever care may be bestowed in the preparation of its food, 
whether cow's or goat's milk, or farinaceous substances be used, there 
is seldom that healthy nutrition which is observed in infants who receive 
the breast-milk. The "swill milk" in common use among the poor 
families of this city is totally unfit for the feeding of infants, and is apt 
to cause flatulence, acidity, and indigestion. Acute indigestion occurs 
in children of any age from food unsuitable in quality «or quantity, which 
produces gastralgia and other symptoms to be detailed hereafter. Those 
who suffer habitually from malassimilation are especially liable to such 
acute attacks. 

In the period of childhood, chronic indigestion is much less frequent 
than in infancy, but children are, perhaps, more subject than infants 
to the acute form. This is induced by ingesta taken in too large quan- 
tity, or of a kind which is with difficulty digested. Cherries, currants, 
raisins, and the parenchyma of oranges and lemons, dried fruits, and 
confectionery, which are so often heedlessly given to children, are com- 
mon causes of acute attacks of indigestion. These substances, being 
but partially digested or not at all, and sometimes accumulating for days 
in the stomach or intestines, may lead to a very serious and dangerous 
condition. 



SYMPTOMS. 699 

Symptoms. — Before describing the symptoms of indigestion I wish 
to direct attention to one form of vomiting in young infants which is 
usually attributed to indigestion by the young practitioner, but which 
really has no pathological significance. I refer to vomiting or regurgi- 
tation of milk in hearty and well-nourished infants, resulting from too 
frequent nursing or over-nursing. It occurs without previous nausea, 
and with little effort. The relatively small size of the stomach in young 
infants, its position more vertical than in older children, and the little 
development of the fundus, which is the proj)er receptacle of the milk, 
favor this regurgitation. The milk that is ejected is unchanged if it 
be returned immediately after the nursing, but if some moments have 
elapsed the casein is more or less coagulated. Little harm is done by 
this loss of nutriment, if the infant appear well and thriving. It is, 
indeed, salutary, for if the food, that is in excess of what is wanted, and 
in excess of what can be digested, be retained, it undergoes fermenta- 
tion, and becoming an irritant causes indigestion and diarrhoea. The 
remedy consists in less frequent or less prolonged nursing, and allowing 
the infant to lie quietly in the crib after each nursing. 

But vomiting is a symptom that should always arrest attention, and 
its cause be ascertained. If the child cease to grow, and lose its vivacity, 
the vomiting has pathological significance. Frequent vomiting, without 
other marked symptoms referable to the digestive apparatus, and with 
evident loss of flesh and strength, is, in most cases, a symptom of gastric 
indigestion, or of incipient meningitis. The presence of mucus in the 
ejected matter, eructation of gas, and the apparent absence of headache, 
and of other meningeal symptoms, apart from the vomiting, aid in estab- 
lishing the diagnosis of gastric indigestion. 

With these preliminary remarks, we will proceed to consider the 
symptoms, first, of habitual, and next, of acute temporary indigestion. 

The nursing infant, if the milk continually disagree with it, is fret- 
ful. It has a discontented aspect ; it seldom smiles, and is not amused 
by playthings, or is only amused for a short time. Its features are 
pallid, and bear the appearance of faulty nutrition. Its body and limbs 
are more or less wasted, or are soft and flabby. Vomiting is frequently 
present, and sometimes a large mass or masses of casein are ejected, 
which have evidently lain a considerable time in the stomach. The 
bowels may be constipated or loose, and the evacuations are unhealthy. 
This state of the infant continuing prevents the necessary rest of the 
mother, and may affect unfavorably her health, so as to reduce the quan- 
tity of her milk, or render it still more unwholesome. 

In habitual indigestion of young children fermentation of the food 
occurs to a great extent, instead of normal digestion, and the fermen- 
tation results in the production of acids. Whatever irritates the gastro- 
intestinal surface, causes an increased secretion of mucus, and it is 
believed that the mucus, since it is alkaline, prevents to a great extent 
the digestive action of the pepsin, which requires an acid medium, so 
that lactic, butyric, and the fatty acids result. This acid fermentation 
beginning in the stomach, extends to the intestines as the food is carried 
downward. Hence the acid breath, sour-smelling ejecta, fetid stools, 



700 INDIGESTION. 

flatulence and colicky pains, indicating both gastric and intestinal dys- 
pepsia, so common in young improperly fed infants. 

Habitual indigestion is, as might be expected, more common and 
severe in artificially fed infants, than in those at the breast, and it 
is more likely to result in gastro-intestinal catarrh. In rural localities 
where children are much of the time in the open air, have good consti- 
tutions, active digestion, and fresh food, dyspepsia is comparatively rare, 
but in large cities, in which the conditions of life are so different, its 
occurrence is common. Gross carelessness in the feeding, and ignor- 
ance on the part of mothers of the dietetic requirements of young chil- 
dren, contribute greatly to its frequency. 

Attacks of acute indigestion not infrequently occur from careless and 
improper feeding, in children who are habitually dyspeptic, as well as in 
those whose digestive function is usually well performed. In these acute 
attacks young children, especially infants, often suffer much from colicky 
pains, gastralgia or enteralgia. Their countenance indicates suffering, 
they utter sharp cries; their thighs are flexed over the abdomen, and 
moved from side to side. Warm spirituous lotions, friction or gentle 
pressure upon the abdomen, gives some relief, especially if it be attended 
by the expulsion of flatus. Vomiting, or an evacuation of the bowels, 
commonly removes the offending substance, and the pain subsides. 

Attacks of acute indigestion come on suddenly, and occasionally are 
so severe that they produce dangerous symptoms, as eclampsia. Apart 
from pain, or a sensation of weight or fulness in the abdomen, symp- 
toms of a reflex character frequently occur, such as headache, drowsiness 
or languor, sudden twitching of the limbs premonitory of convulsions, 
and even severe or repeated convulsions. One of the most severe 
attacks of eclampsia which I have seen, occurred in a boy of eight or 
ten years, induced by swallowing the pulp of oranges, which he had been 
in the habit of eating, and which had accumulated in the stomach and 
intestines. The expulsion of the offending substance gave immediate 
relief. In some children with acute indigestion, the pulse is notably 
accelerated, the face flushed, the surface hot, and the temperature ele- 
vated two or three degrees above normal. 

As the child advances in years, and becomes stronger, its digestive 
function is more active, a greater variety of food can be assimilated, and 
indigestion, whether temporary or habitual, is less frequent than in the 
first years of life. 

Prognosis. — Indigestion in the adult, when not due to organic dis- 
ease, involves little danger to life, but in infancy its consequences are 
often serious. Habitual indigestion in the infant, whether due to the 
bad quality of the breast-milk, or to artificial feeding, is liable to cause 
inflammation of the buccal, oesophageal, gastric, or intestinal mucous 
membrane, and, in some patients, of two or more of these divisions of 
the intestinal tract. Thus, especially in the warm months, the acid 
products of indigestion often cause a dangerous catarrhal inflammation, 
accompanied by vomiting and frequent stools. Many cases of atrophy 
in infants, characterized by arrested growth and gradual loss of flesh 
and strength, till, perhaps, the features have a sunken and senile ap- 
pearance from the waste, and the skin lies in wrinkles, originate in 



DIAGNOSIS — TREATMENT. 701 

habitual indigestion. Henoch points out the frequency of gastro- 
malacia in infants who have suffered from severe indigestion accompa- 
nied by the abundant production of acids. The softening of the stomach 
is believed to be largely, if not entirely, cadaveric, the result of post- 
mortem digestion, from the presence of pepsin and the acids of fer- 
mentation. The gastric mucous membrane can be readily scraped away 
by the nail, and it presents a gelatiniform appearance. Sometimes even 
the stomach is perforated, and the adjacent organs are acted on by the 
corrosive liquids. 

If the dyspepsia have not continued so long as to cause inflammatory 
complications, prompt recovery is probable by the use of suitable food 
and corrective medicines. If such complications be present, recovery 
can only be gradual. 

Diagnosis. — Habitual indigestion does not usually continue long 
without the occurrence of more or less gastro-intestinal catarrh. The 
poor nutrition and appetite, the unhealthy, flatulent stools, containing 
mucus, the vomiting, and occasional colicky pains, are symptoms which 
plainly indicate a dyspeptic origin. Attacks of acute indigestion are 
also easily diagnosticated, in most instances, by the sudden occurrence 
of the symptoms, such as vomiting, pain in the abdomen, or a sensation of 
fulness, eructation of gas, etc., and the speedy subsidence of symptoms 
when the cause is removed. But sometimes, especially in children over 
the age of two or three years, the symptoms may so closely resemble 
those of other acute diseases, that a careful examination is required in 
order to make a clear and correct discrimination. Thus I have related 
above the history of a case in which the febrile movement and expira- 
tory moan closely resembled those of pneumonia, but the symptoms 
quickly abated on the expulsion of a considerable quantity of orange- 
pulp. An attack of acute indigestion, attended by vomiting, rapid 
pulse, elevated temperature, with perhaps some erythema, may be mis- 
taken for the commencement of one of the febrile diseases to which chil- 
dren are so liable. If, on examination of the fauces, no redness of the 
throat be observed, scarlet fever and diphtheria can be excluded. By a 
free evacuation of the bowels, the symptoms abate, and the attack ends, 
so that if there were any doubt in the diagnosis it is soon dispelled. 

When eclampsia results from an attack of acute indigestion, the 
physician is often compelled to act promptly without a clear diagnosis, 
but the result of treatment soon renders the nature of the attack 
apparent. 

Treatment. — The first indication in treatment is obviously the re- 
moval of the cause. In acute indigestion, when there is reason to 
believe that there is some offending substance in the stomach or intes- 
tines, if the symptoms occur soon after the substance is taken, an emetic 
may be administered, and ipecacuanha, in syrup or powder, is a safe 
and usually efficient remedy. If several hours have elapsed a purgative 
should be given, as castor oil, either alone or in combination with syrup 
of rhubarb. 

If the symptoms be urgent, especially if convulsions be threatened, 
we should not wait for the slow action of a purgative, but should resort 
to enemata to open the bowels. Sometimes the pain in acute indiges- 




702 INDIGESTION. 

tion is such as to require the use of opiates. In the infant there is often 
an excess of acid in the stomach and intestines, which is best treated by 
alkaline remedies, as lime-water in combination with the opiate. The 
following mixture will be found useful in such cases: 

R. — Tinct. opii deodorat., or liq. opii composit. (Squibbs) . gtt. xij. 

Magnes. calcinat. . . . . . . . * . gr. xij — xxiv. 

Sacch. alb. zj. 

Aq. anisi g iss. — Misce. 

Dose, the bottle being first shaken, one teaspoonful every two hours to a child a 
year old, until relief. If there be much pain, it is well to add a little chloroform 
or Hoffman's anodyne to the mixture. 

Or the following mixture : 

R. — Tinct. opii deodorat., or liq. opii composit. 

Bismuth, subcarbonat. ....... 

Syr. simplic. 

Aq. cinnamomi ......... 

Shake bottle thoroughly and give one teaspoonful. 

If in the acute indigestion of infants diarrhoea occur, the camphorated 
tincture of opium, in combination with chalk mixture, may be given, 
fifteen drops of the one to a teaspoonful of the other, or the above mix- 
ture. Infants, whose diet consists largely of cow's or goat's milk, 
digest with most difficulty the casein, which often passes the bowels in 
an imperfectly digested state, or it collects in a large and firm mass in 
the stomach, causing gastralgia and rendering the child fretful till it is 
vomited. I have elsewhere recommended, as important to prevent these 
attacks of acute dyspepsia, the use of the upper third of the milk, which 
contains less than the average casein, and the addition of an alkali to 
the milk, which retards coagulation till it begins to be acted upon by 
the gastric juice, and tends to prevent the formation of large and firm 
caseous coagula in the stomach. The addition of a little farinaceous 
food, as barley water to the nursing-bottle, will sometimes produce the 
same effect by mechanically separating the particles of milk. Pep- 
tonized milk, as recommended in our remarks on the hygienic treatment 
of intestinal catarrh, will also be found useful in certain cases. 

In ehronic indigestion the means of relief are different. They are 
twofold : first, as regards change of diet ; secondly, measures to improve 
the digestive function. Spoon-fed infants, suffering from habitual in- 
digestion, require the utmost care as regards the character of their food, 
its preparation, and the times of feeding. Often it is best, if practica- 
ble, to procure a wet-nurse, and sometimes removal ,to a more salubri- 
ous locality is followed at once by improvement in the digestive function. 
If the infant be already wet-nursed, the milk should be examined 
microscopically and otherwise, and inquiry should be instituted in refer- 
ence to the health and diet of the wet-nurse. Sometimes a change of 
wet-nurse is advisable. For facts and considerations bearing on this 
point the reader is referred to the chapters relating to regimen. 

Children with chronic indigestion are occasionally much benefited by 
the moderate and judicious use of alcoholic stimulants. They should be 
given sparingly with their food, and should be discontinued as soon as 



TREATMENT. 703 

the digestive function is fully restored. M. Donne and some other 
French writers recommend the habitual use of wine for infants even in 
a state of health, but there are reasons, moral as well as physical, why 
alcoholic stimulants should only be used as medicines, and not in a state 
of health. 

If the case be one of simple or uncomplicated indigestion, pepsin or 
lactopeptin of the shops and tonics may be employed. In many in- 
stances, however, especially in infancy, gastro-intestinal inflammation 
has supervened, and in such cases those remedies should be employed 
which exert a favorable, or, at least, not an unfavorable effect on the 
inflamed surface over which they pass. 

In habitual indigestion remedies are obviously required which in- 
crease the quantity of the digestive ferments. The following will be 
found a useful prescription in cases of indigestion in which gastro- 
intestinal catarrh has supervened: 



. — Acidi hydrochlorici dilut. . 


. gtt. xvj-xxxij 


Lacto-peptini or pepsini . 


• 3\\ 


Bismuth, subnitrat. . . 




Syr. simplic. ..... 


5ss. 


Aquae destillat. ..... 


3 iij . — Misce. 



Shake bottle, and give one teaspoonful before each feeding. 

If the stools continue frothy and offensive on account of the fermenta- 
tion, the following will be found beneficial : 

R . — Creasoti or acidi carbolici ..... gtt. ij to iv. 

Syr. simplic. . . . . . . 5ss. 

Aquae destillat. ....... 5Jss. — Misce. 

Dose, one teaspoonful every two hours. 

In children over the age of three or four years, the vegetable tonics 
are often useful, as quinine in half-grain or one-grain doses, and the 
elixir of calisaya bark. Iron may also be given, especially the milder 
preparations, as the citrate in aniemic cases. 

Among the useful vegetable stomachics and tonics may also be men- 
tioned the compound tincture of cinchona, compound tincture of gen- 
tian, infusion of columbo, fluid extract of columbo, and fluid extract of 
cinchona. 

If chronic indigestion be complicated with gastro-intestinal inflamma- 
tion, subacute or chronic, for this is the form which is usually present, 
there are still certain tonics which may be advantageously administered. 
Columbo and the compound tincture of cinchona are often useful in these 
cases, and of the chalybeates wine of iron or the citrate of iron and 
ammonium or the liquor ferri nitratis may be safely administered. In 
most cases, however, change in the diet properly made will be found 
more useful than tonic and corrective medicines. 

Infants affected with diarrhoea from indigestion often improve under 
the use of powders consisting of equal parts of subnitrate of bismuth and 
pepsin or lactopeptin. An infant of three. months can take three grains 
of each every three hours, or before each feeding. 

Dyspepsia often rapidly disappears by hygienic measures without the 
use of medicines, as by removal from the city to the country, outdoor 



704 GASTRITIS. 

exercise, or, if the patient be an infant, by being carried into the open air 
daily. In infants, also, marked improvement is often observed on the 
approach of the cool and bracing weather of autumn and winter. 



Congestion of the Stomach. 

Passive congestion of the stomach is described among the diseases of 
this organ by Billard ; but it is a pathological state of little importance 
in itself. It occurs in newborn infants, asphyxiated at birth and with 
difficulty resuscitated. In these cases there is generally intense capil- 
lary congestion throughout the system. The mucous membrane of the 
stomach is injected, but not more than that of the mouth or intestines. 
If circulation and respiration be fully established, this injection of the 
capillaries subsides. No treatment is required, except measures to pro- 
mote the circulatory and respiratory functions. In cyanosis and atelec- 
tasis there is often general congestion of the capillaries of the systemic 
•circulatory system, on account of the obstruction to the flow of blood 
through the heart in the one disease and through the lungs in the other. 
There is in these cases passive congestion of the stomach, but not more 
than of other organs. 

Gastritis. 

Inflammation of the stomach, except when produced by the direct 
contact of some irritant, is rare in infancy and childhood, independently 
of disease in some other portion of the intestinal tract. Cases have, 
however, been reported in which it was not known that any irritating 
ingesta had been taken, and in which a careful examination revealed a 
healthy or nearly healthy state of other portions of the digestive tube. 
The subjects were, for the most part, young infants. The following is 
an example related by Billard : 

An infant, four days old, remarkable for the color of his face and 
firmness of flesh, refused the breast, and vomited yellow, acid matter. 
On the following day the vomiting had increased, the legs were oedema- 
tous, face pallid and pinched, respiration difficult, skin cold, pulse slow 
and irregular, and pressure on the epigastric region produced cries indic- 
ative of pain. 

Third day : general sinking ; face thin and expressive of great pain ; 
stools natural. 

Fourth and fifth clays : condition the same. Death occurred on the 
sixth day ; and the autopsy was made on the day following. 

With the exception of slight pneumonitis, no disease was discovered 
in any part of the system beside the stomach. The mucous membrane 
of this organ was intensely vascular near the cardiac orifice and along 
the lesser curvature. This part was also tumefied, and could be easily 
raised with the finger-nail. The remainder of the gastric surface was 
hypergemic, but to a less extent. 

This case is interesting as showing what may happen, though rarely. 
A nursing infant is seized with gastritis without apparently having taken 



AGE. 705 

any irritating ingesta, and without other disease of the digestive appa- 
ratus. It is probable, however, that, in cases like the above, the cause, 
if ascertained, would be found in the ingesta ; perhaps drinks too hot, 
perhaps elements of colostrum, or pathological elements in the milk, 
which might produce gastritis in young infants in whom the mucous 
membrane is delicate and sensitive. 

Gastritis is not uncommon in infancy in connection with inflamma- 
tion of the intestines. The latter inflammation is sometimes apparently 
subordinate to the former, and, if such patients die, the fatal result is 
due mainly to the gastric disease. The reverse is, however, the rule. 
The gastritis is ordinarily subordinate to the intestinal catarrh. 

Cause. — Gastritis, as I have observed it in infants, has been in most 
cases due in great part to the continued use of improper food, of food 
not suitable to the age of the child, and which was, therefore, with dif- 
ficulty digested. Milk, acid or otherwise unwholesome, farinaceous 
substances, stale or of an inferior quality, and not properly prepared, 
drinks too hot or too cold, may be specified among the causes. There- 
fore, this disease is most common in bottle-fed infants, and is compara- 
tively rare in those who receive abundant and wholesome breast-milk. 
Anti-hygienic agencies, apart from the diet, no doubt exert some influ- 
ence in the production of gastritis, as they do of stomatitis. Unclean- 
liness, and residence in damp and dark apartments, or in an atmosphere 
loaded with noxious gases, produce a condition of system which strongly 
predisposes to these inflammations, if, indeed, they may not be enumer- 
ated among the direct causes. 

Rilliet and Barthez have called attention to the fact that certain 
medicinal substances given to children occasionally cause gastritis. 
They have observed this effect from the use of tartar emetic, kermes 
mineral, and croton oil. Gastritis occurring in this way may or may 
not be associated with inflammation in contiguous portions of the diges- 
tive tube. Elsewhere I have related a case in which gastro-enteritis 
occurred in a child nine years old, after having taken a considerable 
quantity of kerosene oil for spasmodic croup ; and Dr. ISTorthrup, curator 
of the N. Y. Foundling Asylum, has seen the lesions of gastritis in 
infants that took carbonate of ammonium in the last days of life. 

Inflammation of the stomach is thought by some to accompany 
measles and scarlet fever during the eruptive period, but this opinion is 
probably incorrect. If it occur, it corresponds with the stomatitis and 
dermatitis of those diseases, and disappears as they subside. It is mild, 
and accompanied by few symptoms. I have, as stated in the remarks 
on scarlet fever, examined in certain instances the stomachs of those 
who have died during the eruptive period of these diseases, and found 
them free from any appreciable inflammatory lesion. 

Age. — From the records of about seventy cases of inflammatorv dis- 
ease of the digestive mucous membrane which I have preserved, it 
appears that gastritis is rare over the age of six months. On the other 
hand, it is not uncommon in infants under the age of three months who 
are deprived of breast-milk. I have met it chiefly in foundlings fed 
with the bottle, and having at the same time entero-colitis and often 
also stomatitis and oesophagitis. In these cases there is sometimes con- 

45 



706 GASTRITIS. 

tinuous or almost continuous injection and thickening of the mucous 
membrane, from the lips to near the pyloric orifice of the stomach, and 
even beyond this orifice in the intestines. The following is an example 
of gastritis as it frequently occurs in foundling institutions : 

Case. — R. AV., female, two weeks old, was admitted into the Xew York 
Infant Asylum, August 24, 1865, anaemic and somewhat emaciated. She 
was in part wet-nursed, and in part bottle-fed. The emaciation increased, 
and nearly the entire buccal cavity became covered with the confervoid 
growth of thrush. On September 4th, diarrhoea commenced. Borax was 
used for the mouth, and alkalies and astringents to check the diarrhoea, 
but without material improvement. 

The following was the record for September 7th : " Cries almost con- 
stantly, with feeble or whining voice ; still has thrush; nurses and does 
not vomit ; stools five or six daily, and green ; pulse 136, feeble." Death 
occurred September 8th. 

Autopsy September 9th. — Mouth and fauces not examined ; mucous mem- 
brane of oesophagus vascular in its whole extent, with slight thickening, 
but without ulceration ; mucous membrane of stomach injected like that 
of the oesophagus, and somewhat thickened, except in its pyloric extrem- 
ity, where the appearance was natural, or nearly so ; the color in the cen- 
tral part of the inflamed gastric membrane was deep red ; no thrush was 
noticed, except on the buccal surface during life ; along the great curvature 
of the stomach were white flakes, resembling those of thrush, but which 
were found by the microscope to consist mainly of oil-globules and epithe- 
lial cells, without the cryptogamic formation ; mucous membrane of small 
intestines healthy in their whole extent, except slightly increased vascu- 
larity in a few places in the ileum; mucous membrane of colon much 
injected throughout, except near the ileo-csecal valve, where the vascu- 
larity was slight ; in the transverse and descending colon the redness was 
pretty uniform; and the membrane was thickened, but not ulcerated; 
solitary glands and Peyer's patches moderately elevated. 

The observations of Valleix show how frequently gastritis is associated 
with severe attacks of thrush. In twenty-three of his cases of the latter 
disease, in which the condition of the stomach was noted after death, 
this organ presented inflammatory lesions in seventeen, and in three 
others appearances which may or may not have been due to inflammation. 

Symptoms. — A difficulty exists in isolating and defining the symp- 
toms of gastritis, from the fact that it commonly coexists with other in- 
flammations of the digestive tube. Though we may never be able to 
diagnosticate this catarrh as certainly as we can croup or pneumonitis, 
still, there are symptoms which arise directly from the gastritis, and 
with care we may be able to distinguish them from those symptoms 
which are due to other pathological states. 

If gastritis be acute, pain is present. In the above case from Billard, 
as well as in a case observed by myself and related under the head of 
gelatinous softening, there were frequent cries, and the countenance in- 
dicated much suffering, until the stage of collapse. If there be less 
intensity of inflammation, and the disease be more protracted, as is ordi- 
narily the case, the pain is not so severe, and it may be so slight as not 
to attract attention. Sometimes there is tenderness, so that pressure 
upon the epigastric region is badly tolerated. Vomiting is regarded as 



DIAGNOSIS — PROGNOSIS. 707 

one of the most constant symptoms. The infant after nursing seems in 
distress till the milk is returned, but it nurses with avidity in conse- 
quence of the thirst, if it be not too exhausted or feeble. The dejections 
may be quite regular throughout the disease, as in the case from Billard. 
There is ordinarily, however, diarrhoea from the presence of entero- 
colitis. The pulse is sometimes accelerated, and sometimes nearly 
natural. The emaciation in gastritis is rapid, since not only the milk 
is in great measure vomited, but the digestive function, so far as the 
stomach is concerned, is seriously impaired. The features become 
wrinkled and senile, the eyes hollow, the limbs attenuated, and the 
cranial bones uneven. Death occurs from exhaustion. 

Anatomical Characters. — Simple gastritis may affect the entire 
mucous surface of the stomach, or be limited to a certain part. The part 
which is most likely to escape is that toward the pyloric orifice. This 
portion of the organ is sometimes found in nearly or quite the normal 
state, while the cardiac half or two-thirds is inflamed. The vascularity 
of the diseased surface is not uniform. In one place there is simple 
arborescence ; in another intense continuous redness, and between these 
two extremes are different grades of vascularity. The mucous mem- 
brane is somewhat thickened, softened, and the secretion of mucus in- 
creased. Extravasation of blood is not infrequent under the mucous 
membrane, usually in points, and mucus may be mixed with more or 
less blood. Small shreds or portions of coagulated milk are often found 
with the mucus attached to the gastric surface. I have observed, though 
rarely, small superficial ulcers at the point where the inflammation had 
been most intense. 

Diagnosis. — In protracted cases, when entero-colitis is present, it is 
difficult to make a positive diagnosis. Our opinion must then be little 
more than a plausible conjecture. In the acute attacks we can diagnos- 
ticate the gastritis with more certainty. If a young infant affected 
with sprue be seized with pain, and it vomit often ; if emaciation be 
rapid, and there be no diarrhoea, or diarrhoea not sufficient to account 
for the prostration ; if the buccal mucous membrane, dotted with the 
points of thrush, present a dry appearance and the deep red color of 
severe stomatitis, there can be little doubt of the presence of gastritis. 
The diagnosis is rendered more certain by signs of tenderness when 
pressure is made upon the epigastric region. 

Prognosis. — Like other inflammations, gastritis is probably sometimes 
so mild that it does not materially increase the suffering or danger of the 
child. This mild form of the disease under favorable circumstances soon 
subsides. In other cases, by the continuance or increase of the cause, 
the inflammatory process becomes more severe and extensive, resulting 
even in disintegration of the mucous membrane. Those cases are espe- 
cially severe and likely to end fatally, which are protracted and accom- 
panied by severe thrush, with a desiccated appearance of the buccal 
surface, or with entero-colitis. Pain, vomiting, and rapid emaciation 
in such children indicate the speedy approach of death. Improvement 
in the stomatitis or entero-colitis is a favorable indication, but these 
inflammations may improve without corresponding improvement in the 
gastritis. 



708 DIPHTHERITIC GASTRITIS. 

Treatment. — All food or drinks, except those of a bland and unirri- 
tating nature, should be forbidden. If practicable, the young infant 
should take no nutriment except the mother's milk or that of a wet- 
nurse. Since there is an excess of acid in inflammation of the mucous 
coat of the digestive tube, lime-water may be advantageously given in 
combination with breast-milk. Opium is required to relieve the pain 
and quiet the action of the stomach. The camphorated tincture of 
opium, in doses of four or five drops to a child a month old, or the 
syrup of poppy, tincture of opium, or liquor opii compositus, in propor- 
tionate doses, may be administered. If there be thirst, a little gum- 
water should be given frequently. If there be much emaciation and the 
vital powers are failing, it will be necessary to resort to the use of stim- 
ulants. Stimulating enemata are preferable to stimulants given by the 
mouth. Much benefit may be anticipated from local measures. Irri- 
tation should be produced upon the epigastrium by mustard or other 
means, followed by fomentations. It is rarely, perhaps never, proper 
to use leeches, if the patient be a young infant. Death occurs from 
exhaustion, and it is, therefore, important that the vital powers should 
not be reduced. If the child be weaned, the diet at first should be 
restricted to arrowroot, rice-water, barley-water, or similar bland sub- 
stances. In advanced stages of gastritis, animal broths and jellies may 
be required. 



Follicular Gastritis — Diphtheritic Gastritis. 

The pathological character of follicular gastritis is similar to that of 
follicular stomatitis. It is an inflammation affecting the gastric follicles 
and ending in their ulceration. It is not a frequent disease ; it occurs 
in young infants. Billard observed fifteen cases. The symptoms in 
these patients were similar to those in simple gastritis of a severe form. 
The emaciation and prostration were rapid, and death occurred early. 
We can only diagnosticate the gastritis without determining its follicular 
character. How many recover it is impossible to ascertain, but the 
disease is likely to be fatal on account of the intensity of the inflamma- 
tion, not only of the follicles but of the intervening mucous membrane. 
The treatment is that of gastritis. 

Diphtheritic gastritis is infrequent. It occasionally occurs during 
epidemics of diphtheria. Allusion is elsewhere made to a case treated 
in the Nursery and Child's Hospital of this city, in December, 1859. 
The patient, eighteen months old, previously had had protracted entero- 
colitis, and died exhausted after a brief attack of diphtheria. There 
were lesions referable to the entero-colitis, and the body was much 
emaciated. The diphtheritic exudation was found covering the fauces, 
epiglottis, glottis to the rima glottidis, the entire oesophagus, and 
almost the entire stomach. The mucous surface underneath was in- 
jected; that of the oesophagus and stomach especially was very vascu- 
lar, softened, and thickened, and the submucous connective tissue was 
infiltrated. 

The pseudo-membrane, taken from the epiglottis and examined under 



SOFTENING. 709 

the microscope, presented an amorphous appearance ; no cells were 
noticed in it, and fibrillation was not distinct ; that from the stomach 
was found to consist almost entirely of cells, the plastic corpuscles of 
some writers, the pyoid of others. The digestive process, so far as the 
stomach was concerned, had evidently been almost if not entirely sus- 
pended, and hence in part the sudden prostration. Diphtheritic gas- 
tritis probably does not occur without general infection of the system 
with the diphtheritic virus. The proper treatment is the use of lime- 
water or one of the solvents of pseudo-membranes which do not irritate 
the mucous membrane, while the constitutional treatment proper for 
diphtheria is employed. 



Post-mortem Digestion — Softening. 

It is now many years since the attention of the profession was 
directed to disorganization of the coats of the stomach, which is some- 
times observed at post-mortem examinations. John Hunter first ascer- 
tained that the gastric juice begins to have a solvent effect on the tis- 
sues of the stomach soon after death. Though Hunter erred, when he 
stated that the coats of the stomach are more or less digested in all 
or nearly all cases, it is certain that post-mortem digestion does take 
place in many cadavers, so that in a few hours after death the gastric 
mucous membrane is destroyed to a greater or less extent, and occasion- 
ally the stomach is perforated or is even severed from its connection 
with the oesophagus. I have seen several examples of this post-mortem 
digestion in infants. 

Some of the cases of supposed pathological softening of the stomach 
reported by the older observers, seem to have been such as I have 
described, namely, cadaveric. Yet there are two other kinds of soften- 
ing occurring in children, which are strictly pathological, the one 
designated white, the other, by Cruveilhier, gelatinous. 

White softening of the gastro-intestinal mucous membrane results 
from deficient alimentation. It has been observed only in anaemic and 
ill-nourished children. The mucous membrane in such patients loses its 
firmness, and is easily separated from the subjacent tissue. This soft- 
ening has no connection with any inflammatory process. It is the 
result of the low vitality of the patient. I believe that, in a large pro- 
portion of infants whose systems have been reduced and blood impover- 
ished for a considerable time, the gastro-intestinal mucous membrane 
will be found after death less firm and resisting than in those who have 
been habitually robust. 

A vague opinion exists in the minds of most physicians as to the 
nature and even appearance of the so-called gelatinous softening of the 
stomach, and the following observations will be cited in order to give a 
clearer idea of it. 

Billard has recorded two cases with his usual minuteness, and adds : 
" What inference shall be drawn from the preceding facts and considera- 
tions? None other than that the gelatinous softening of the stomach 
consists in a disorganization of the mucous membrane of this viscus, 



710 SOFTENING. 

caused by an acute or chronic phlegmasia; that this disorganization is 
characterized by an accumulation of serum in the walls of this organ ; 
the intumescence and gelatinous consistence of the mucous membrane 
in a part usually circumscribed, situated more frequently in the greater 
curvature, and about which the membrane exhibits more or less evident 
traces of an acute or chronic phlegmasia. . . . The softening now 
under consideration must not be confounded with another kind of soften- 
ing " (white) "which does not usually succeed an acute phlegmasia." 

Billard believes that, while gelatinous softening results from inflam- 
mation of the mucous membrane, its proximate cause is an afflux of 
serum to the part in which the disorganization occurs. In one of the 
two cases which he reports, he thinks that the inflammation was acute, 
but in the other chronic, and, therefore, presenting less vascularity. 

West, in speaking of gelatinous softening, says: "Softening of the 
stomach varies in degree from a slight diminution in the consistence of 
the mucous membrane, to a state of complete diffluence of all the tissues 
of the organ. . . . When the change is not far advanced, the ex- 
terior of the stomach presents a perfectly natural appearance, but on 
laying it open a colorless or slightly brownish tenacious mucus, like the 
mucilage of quince-seed, is found closely adhering to its interior, over a 
more or less considerable space at the great end of this organ." 

Cruveilheir says: "This softening often proceeds from the interior 
toward the exterior. There is at the beginning simple separation of 
the fibres by a gelatinous mucus, and in consequence the parietes are 
thickened and semi-transparent. ... If the transformation be 
complete, the disorganized portions are removed layer after layer, those 
which remain becoming gradually thinner. The peritoneum alone re- 
sists for some time, but at length it is attacked, worn, and gives way, 
and perforation of the stomach results. The parts thus transformed are 
colorless, transparent, apparently inorganic, completely deprived of ves- 
sels, and exhaling an odor resembling that of milk." 

Bouchut remarks: " Softening of the mucous membrane of the stom- 
ach in children at the breast is not a special disease which it is necessary 
to describe by itself. This alteration is always connected with other 
diseases, and especially with disease of the large intestine, the knowl- 
edge of which fact has been too long neglected. It is the consequence 
of the acidity of the liquids contained in the digestive tube of young 
children, liquids which are very acid in the disease Ave have above re- 
ferred to." 

Dr. Carswell states that there is a pathological softening of the 
mucous membrane of the stomach, and that when it occurs the symp- 
toms may be those of gastritis or enteritis. 

Rokitansky says of this form of softening: "If we consider, in addi- 
tion to the above remarks, the uniform localization of the disease, that 
in none of its stages it presents, either at the point of the softening or 
in its vicinity, hypenemic injection or reddening, and that we are still 
less able to demonstrate upon the inner surface of the stomach or in the 
tissue of its coats the products of inflammation, we are constrained to 
infer the non-inflammatory nature of the affection. 

Without extending these extracts, it is seen that eminent authorities 



SOFTENING. 711 

not only disagree in reference to the cause of gelatinous softening of the 
stomach, but that they also differ in their description of its appearance. 
This diversity of opinion is most likely attributable to the fact that the 
two kinds of softening have been confounded. Rokitansky and Bouchut 
probably refer to cases of white softening, which occurs in atonic states 
of the tissues in feeble infants, and, therefore, have concluded that 
softening of the stomach is not inflammatory. I believe, from my ob- 
servations, that the opinion of Billard is correct, and that true gelati- 
nous softening is the result of gastric inflammation, sometimes chronic, 
sometimes acute. But I have seen appearances which led me to think 
that the immediate causes of the softening continue to operate after 
death, se that its amount is less at the time of death than a few hours 
subsequently. 

The following case, which was watched by myself with great interest, 
from beginning to end, is an example of inflammatory softening: 

Case. — G. S., male, robust, was born July 10, 1865. The mother not 
being able to suckle the infant, and the danger of artificial feeding in the 
warm months being well understood, a wet-nurse was procured. About 
the 14th of July, this wet-nurse having insufficient milk, another was pro- 
cured temporarily, who suckled the infant till July 20th, when a third 
wet-nurse was engaged, whose child, healthy and thriving, was six weeks 
old. Previously to this time the infant appeared well. It had uniformly 
nursed vigorously and seemed satisfied. 

On the 2 2d of July, thrush, apparently mild, was observed in the 
mouth, and a powder, supposed to be borax, and labelled such, was ob- 
tained at a drug-store, to be used as a wash for the mouth. This powder 
was afterward ascertained to be alum. Five grains were dissolved in 
as many teaspoonfuls of water, and the mouth of the child was swabbed 
occasionally with it. A piece of linen, folded so as to resemble the tip 
of a nursing-bottle, was occasionally dipped into the solution, and the in- 
fant was allowed to suck it. The use of the alum was commenced about 
6 p. M. In the first part of the evening the infant slept considerably, and 
of course did not nurse often, but about 8 p. m. it began to be very fret- 
ful, and it then nursed more frequently. It vomited once between 8 and 
10 o'clock p. m. In order to quiet the infant, the tip soaked in the solu- 
tion was often applied to the mouth, but there was scarcely any intermis- 
sion in its crying. Through the night it vomited again once or twice, 
and about the middle of the night had one free liquid stool, which was 
passed with much tenesmus. The countenance of the infant was indica- 
tive of suffering, and its thighs were repeatedly flexed over the abdomen, 
as if that were the seat of its distress. Paregoric in two-drop doses was 
several times given through the night, and flannel soaked with hot whiskey 
was applied to the abdomen. 

July 23d. In ignorance of the cause of the child's sickness, another 
wet-nurse was obtained early in the morning, and one-sixth of a drop of 
liq. opii compos, was given every hour, with the effect of inducing a little 
sleep. The tongue was very red, desiccated, and studded with more 
numerous points of thrush than on the previous day. It now refused to 
nurse, apparently from soreness of the tongue. At each attempt of the 
nurse to induce it to take the nipple, it rubbed the mouth across the 
breast, crying either from pain or disappointment. The alum was not 
used in the latter part of the night of the 22d, but late in the morning of 



712 SOFTENING. 

the 23d it was resumed, the mistake of the druggist not being discovered 
till midday, when it was estimated that about five grains had been used. 
Occasionally a little of the solution was placed in the mouth with a spoon 
so as to be swallowed, in the belief that the thrush affected the oesopha- 
gus. The infant continued to suffer much during the day, sleeping at 
times a few minutes. Its strength was evidently failing ; respiration reg- 
ular ; pulse about 140 ; its alvine discharges yellow, of natural consistence 
and frequency. 

Evening, 23d. Surface hot; it is very restless; pulse 150 to 160; 
tongue dry, intensely red, aud dotted with points of thrush. Is treated 
with opiates, a little lime-w T ater, and fomentations. 

24th. In the first part of the day nursed pretty well ; in the latter part, 
could be induced to draw the breast only once or twice. The symptoms 
to-day were the same as yesterday, with the exception of greater emacia- 
tion and prostration ; cranial bones uneven, and features pinched. 

25th. Pulse 140 to 148 ; strength rapidly failing, but it cries at times 
loudly. The milk of the nurse, placed in the mouth with a spoon, is 
often held a considerable time before it is swallowed, and deglutition 
seems difficult. Respiration in the first part of the day and previously, 
natural ; in the latter part of the day, accelerated ; dejections natural ; no 
vomiting ; appearance of tongue more natural than yesterday. 

26th. Died to-day in a state of collapse at 12^ p. m. The hands were 
cold several hours before death, and the milk given it was regurgitated. 

Autopsy tiventy-two hours after death. — Much emaciation ; no rigor mor- 
tis ; cranial bones uneven ; the upper part of the pharynx injected to the 
extent of about half an inch ; from this point to the stomach membrane 
healthy ; mucous membrane covering the cardiac two-thirds of the stomach 
disintegrated, almost diffluent, and in places detached from the subjacent 
tissues ; mucous coat of the pyloric third of the organ nearly healthy ; 
along the edge of the softened portion the mucous membrane was vascular 
to the extent of a few lines ; the muscular and serous coats of the stomach 
underneath the softened portion were easily torn ; the mucous membrane 
of the small intestine presented in places that degree of vascularity known 
as arborescence ; there was no destruction or softening of its mucous mem- 
brane ; the colon was healthy ; the stomach was nearly empty ; the con- 
tents of the small and large intestines were natural in color and consist- 
ence ; the other viscera were healthy ; in the left pleural cavity was about 
one ounce of transparent serum, and a less quantity in the right cavity. 

It cannot be doubted that the softening in the above case was patho- 
logical. The weather at the time was warm, but the infant was placed 
on ice, and a pan containing ice was kept upon the abdomen. This 
infant died evidently of gastritis, the accompanying inflammation being 
subordinate, and in fact insignificant. At first it was a question with 
me whether the alum might not have caused the gastritis, so that the 
case should be properly placed in the category of deaths from swallow- 
ing corrosive substances. In order to determine this point, I adminis- 
tered alum daily to two kittens, commencing when they were seven days 
old. The quantity given to each was ten grains daily in two doses for 
three consecutive days, and on the tw T o following days five grains. The 
only uniform result noticed was an increased flow of saliva, which washed 
some of the alum from their mouths, and occasionally slight vomiting. 



NON-JNFLAMMATORY DIARRHOEA. 713 

There was not even any apparent inflammation of the buccal membrane 
from the alum. 

Post-mortem appearances as in the above case, and similar ones 
recorded by Valleix and others, in which gelatinous softening coexisted 
with evident lesions of gastritis, render it highly probable, if indeed 
they do not demonstrate, that the softening is a result of the inflamma- 
tion at the point where it occurs. 

In Valleix's twenty-four cases of what he terms fatal muguet, soften- 
ing of the mucous membrane of the stomach was one of the most com- 
mon lesions, and at the same time, which is the point of interest, there 
were signs which showed conclusively the presence of gastric inflamma- 
tion. The common coexistence of the lesions of gastric inflammation, 
such as redness and thickening, with gelatinous softening of the stomach, 
is certainly most reasonably explained on the supposition that the one 
results from the other. 

I am not prepared to accept nor reject the theory of Billard, that 
the immediate cause of the softening is the afflux of serum, nor that of 
Bouchut, that it is an excess of acid. 

It has been said that M. Baron was able to diagnosticate gelatinous 
softening. The symptoms are those of the severe forms of gastritis. 
The vomiting, great pain, restlessness, sudden and progressive emacia- 
tion, and, finally, collapse preceding the fatal result, without sufficient 
diarrhoea to cause the rapid sinking, are the symptoms on which the 
diagnosis is based. The treatment should be directed to the gastritis. 



CHAPTER VII. 

DIARRHOEA. 

Diarrhoea is frequent during the whole period of infancy. French 
writers describe several varieties, according to the character of the evacua- 
tions, as acescent, mucous, and serous. M. Rostan even describes four- 
teen distinct kinds. But the tendency of medical science in modern 
times is to simplify the nomenclature of diseases — to describe under a 
single name those affections which are essentially the same though dif- 
fering somewhat in their features. Now, all the forms of diarrhoea in 
the infant may be so grouped as to reduce the number to not more than 
three or four. In this way repetition and prolixity are avoided, as well 
as an unnecessary refinement. 

Non-Inflammatory Diarrhoea. 

The most common form of diarrhoea is that enunciated in our head- 
ing, which writers sometimes designate by the term simple or spasmodic. 



714 NON-INFLAMMATORY BIARRHCEA. 

But often a diarrhoea which is n on -inflammatory at first, becomes a 
catarrh. Thus the simple diarrhoea of infancy may become an entero- 
colitis from the continued use of improper diet. 

Causes. — These are various. Conditions or agencies which have no 
appreciable eifect in the adult often increase the number of evacuations 
in young children. Food which imperfectly digests, and some of which 
perhaps ferments, stimulates the intestinal follicles to excessive secre- 
tion, and increases the peristaltic movements by its irritating action, 
thus causing diarrhoea. Too frequent and abundant feeding is another 
cause, especially in young infants, some of whom may vomit the surplus 
food and remain well, but others do not. Food which cannot be assimi- 
lated becomes an irritant in consequence of fermentative change, and 
produces frequent and unhealthy evacuations. The late Dr. James 
Jackson, of Boston, directed attention to this cause of diarrhoea in his 
Letters to a Young Physician. 

The mother's milk or the milk of the wet-nurse may disagree, either 
from some temporary derangement of her system, or continued ill- 
health, or from causes which are not understood. Non-inflammatory 
diarrhoea in the nursling is the immediate result, with perhaps subse- 
quent inflammation. The milk in those cases frequently contains the 
elements of colostrum. 

Fright or strong mental impressions will also in some children increase 
the number of evacuations. This cause being transient, the diarrhoea 
soon subsides. 

Another cause is exposure to cold. Children who are insufficiently 
clothed in the winter season, who are taken from a heated room into a 
cool one without sufficient protection, or who lie uncovered at night, 
are very subject to diarrhoeal attacks from the impression of cold on the 
system. 

The cause of non-inflammatory diarrhoea may exist in the child itself. 
In some children the evolution of the teeth is attended by a relaxed 
state of the bowels, which ceases when the gum is pierced. Worms in 
the intestines may also operate as a cause. Diarrhoea is occasionally 
salutary within certain limits, and of course it is not strictly correct to 
call it a disease when it is a means of relief. If occurring from exces- 
sive or irritating ingesta, it is obviously conservative. 

Symptoms. — Non-inflammatory diarrhoea may come on suddenly ; at 
other times there are precursory symptoms continuing for some days. 
Whether or not there be antecedent symptoms depends chiefly on the 
cause. If this be exposure to cold, or the use of improper aliment, it 
commonly occurs immediately. 

Among the prodromic symptoms sometimes present are restlessness, 
disturbed sleep, transient abdominal pains, nausea, or vomiting, and 
other s}^mptoms of indigestion. The stools in simple diarrhoea differ 
much in color and consistence in different cases, and perhaps at differ- 
ent periods in the same case. In infants they are apt to be green. 
This color, which is a source of anxiety to the inexperienced, and 
especially to the parents, is often produced by trivial causes. Slight 
indigestion will produce it, and so will excess of food, even when bland 
and unirritating. The stools in infantile diarrhoea often contain parti- 



ANATOMICAL CHARACTERS. 715 

cles of coagulated casein, but in children advanced beyond the period 
of first dentition they do not differ materially in appearance from the 
evacuations of the adult. They are usually passed easily, but if they 
be acid or in any way irritating, there may be more or less tenesmus, 
especially in infants. Sometimes before the evacuations, there is a 
sensation of fulness in the abdomen. In that form of diarrhoea which 
has been designated acescent, not only are the stools acid, but matters 
vomited have an acid odor, and give an acid reaction. 

During the quiet hours of sleep, when no food and drinks are taken, 
the diarrhoea diminishes. If the complaint be slight, there is little 
thirst ; but if the stools be frequent and thin, especially if they approach 
the watery character, the patient is thirsty. The appetite varies, the 
tongue is moist, and covered with a light fur, and there is often more or 
less meteorism, but no abdominal tenderness. 

The features in this disease are pallid. In a few days, if the evacua- 
tions continue, there is evident loss of weight and flesh. The rotundity 
of the limbs is gradually lost, and the tissues become soft and flabby. 
But in most cases, when the malady has reached this stage, its original 
character is lost, and it has become inflammatory. 

There is no constant fever in true non-inflammatory diarrhoea. Some- 
times the pulse is accelerated in the latter part of the day, but usually 
only for a short time. 

Certain epiphenomena, as Barrier terms them, occur at times in non- 
inflammatory as well as in inflammatory diarrhoea, as for example a 
sympathetic cough, or, which is more serious, cerebral complications. 
Convulsions or stupor, indicating the supervention of spurious hydro- 
cephalus, may occur in either form of diarrhoea. This disease is de- 
scribed elsewhere. 

Anatomical Characters. — It is obvious from the nature of this 
malady that it is attended by little or no structural changes perceptible 
to the anatomist. In cases supposed to be non-inflammatory, which 
have ended fatally either from the diarrhoea or an intercurrent disease, 
the most marked lesions observed have been more or less tumefaction of 
the intestinal glands, with perhaps diminished firmness and resistance 
of the mucous membrane. Cases like the following, which have usually 
been regarded as non-inflammatory, are not infrequent, but it seems to 
me probable that in at least a certain proportion of such cases the intes- 
tinal follicular apparatus has passed beyond the physiological state of an 
exaggerated functional activity, and that the disease should be desig- 
nated a catarrh or inflammation. Inasmuch as non-inflammatory diar- 
rhoea, if protracted, is very liable to become inflammatory, it is often 
difficult to determine whether the malady has undergone this change, 
even with the aid of a post-mortem inspection. 

On the 7th of July, 1865, a foundling, one month old, died at the 
Infant Asylum. It was much emaciated, with eyes sunken and features 
pinched, at the time of its death. It was wet-nursed toward the close 
of its life, but the nurse's milk was insufficient. It did not vomit; did 
not have any marked acceleration of pulse (128 per minute), and its 
evacuations were about four daily and thin. The stomach and intestines 
were pale throughout. The solitary glands, particularly those in the 



716 NON-INFLAMMATORY DIARRHOEA. 

colon, and the patches of Peyer, were tumefied so as to be visible, and 
somewhat raised above the surrounding surface. But no lesions being 
observed which are characteristic of inflammation, the disease was 
regarded as non-inflammatory. 

Niemeyer, with others, describes even the mildest forms of diarrhoea 
under the term catarrhal inflammation, and he appears to consider the 
transient effects of a purgative as an incipient catarrh. But it seems to 
me preferable, in the present state of pathological knowledge, to regard 
all those diarrhoeas which immediately abate with the removal of the 
cause, and which are attended by no marked anatomical change, as non- 
inflammatory. 

Prognosis. —In a large proportion of cases, non-inflammatory diar- 
rhoea is not dangerous. With the adoption of suitable measures to 
remove the cause, and the use of medicines to control the discharges, 
the patient recovers. The remark already made may be repeated here, 
that occasionally diarrhoea is salutary within certain limits, as when 
there is a foreign substance in the intestines, either irritating mechani- 
cally or by its chemical properties, and which the diarrhoea serves to 
remove. 

The danger arises from complications, as spurious hydrocephalus, or 
from the emaciation and exhaustion, or from its eventuating in inflam- 
mation. 

If the rotundity of the figure and firmness of the tissues be preserved, 
showing that alimentation is still sufficient, and no complication arise, 
the diarrhoea is not as a rule dangerous. In infants that over-nurse 
and do not vomit the surplus milk, the evacuations are sometimes green 
and frequent, and yet fulness of figure is preserved, and the develop- 
ment of the body proceeds as usual. On the other hand, diarrhoea 
attended by emaciation or softness or flabbiness of the flesh, involves 
danger, and requires immediate treatment. 

Treatment. — It is necessary, in order to treat diarrhoea in infancy 
and childhood successfully, to ascertain the cause, and, so far as possible, 
to remove it. It is not till the cause ceases to operate, that we can 
expect a satisfactory result from medication. The disease may be tem- 
porarily relieved by medicine, but it usually returns at once when treat- 
ment is omitted, unless the patient be removed from the influence of the 
agencies which produce it. These remarks are especially applicable to 
the diarrhoea of infants. With them very generally, when affected with 
this complaint, there is some fault as regards the quantity or quality of 
food. Attention to this matter will show the need of a change of wet- 
nurse, or, if the infant be spoon-fed, a change in the character of its food 
or in the mode of preparation or even in the quantity given. Some- 
times by change in the diet, and the adoption of hygienic measures, the 
complaint ceases, so as to require no medication. If medicines be needed, 
and the symptoms are not urgent, it is occasionally advantageous to 
commence treatment by the use of some of the milder purgatives in 
small doses. In the infant, in whom the dejections are so generally 
acid, an alkaline laxative, or a laxative conjoined with an alkali, often 
has a good effect as preliminary treatment. Half a tea spoonful to one 
teaspoonful of castor oil, or a proportionate dose of calcined magnesia, 



TREATMENT. 717 

removes any acid or irritating substance from the intestines, and is fol- 
lowed by a diminution in the number of stools. The improvement, 
however, without subsequent treatment, is usually only for a day or 
two. In this city a purgative dose of castor oil is often given as a 
domestic remedy in infantile diarrhoea, the beneficial effect from it having 
popularized its use for this purpose. Trousseau usually gave Rochelle 
salts, but this medicine is too severe and dangerous for the treatment of 
infantile diarrhoea, especially in warm months. 

If there have been previous constipation, and the diarrhoea have just 
commenced, a purgative, is obviously indicated. West says: "Provided 
there be neither much pain nor much tenesmus, and the evacuations, 
though watery, are fecal, and contain little mucus and no blood, very 
small doses of the sulphate of magnesia and tincture of rhubarb have 
seemed to me more useful than any other remedy : 

R . — Magnesias sulphatis gj. 

Tinct. rhei . . . . . . . gj. 

Syr. zingiberis ........ gj. 

Aquae carui 3 ix. — Misce. 

3J ter die for children one year old ; 

and I seldom fail to observe from it a speedy diminution in the frequency 
of the action of the bowels, and a return of the natural character of the 
evacuations." 

In diarrhoea of infants, due to indigestion, and attended by acidity, 
the following prescription is sometimes useful. By improving diges- 
tion and correcting acidity, it has a beneficial effect on the diarrhoea. 
The cases are, however, in my experience exceptional in which this is 
the proper remedy : 

R. — Pulv. ipecacuanhae gr. ss. 

Pulv. rhei . . . . . . . . gr. ij. 

Sodse bicarb. ........ gr. xij. — Misce. 

Divide in chart. No. xii. One powder every four to six hours to an infant one 
year old. 

The effect of laxative medicines, employed for the purpose of correct- 
ing the functions of the gastro-intestinal surface, is uncertain. If no 
improvement results from their use within two or three days, they 
should be omitted. We must rely on astringents, opiates, and, in 
infants, also on alkalies. If the symptoms be urgent, if the evacuations 
be frequent and exhausting, these agents should be employed from the 
first. Much harm is often done, and pi^ecious time lost, by prescribing 
laxative mixtures when opiates and astringents are required. I have 
know them to aggravate the complaint, w r hen, by change of measures, 
immediate improvement followed. The majority of cases of non-inflam- 
matory diarrhoea, at the period when the physician is called, are best 
treated by the use of astringents and opiates exclusively, proper direc- 
tions at the same time being given in reference to the diet and hygienic 
management. 

In the diarrhoea of infants the compound powder of chalk and opium 
is an excellent medicine, containing, as it does, an astringent with the 
opiate and alkali. It may be given in doses of three grains, to a child 



718 INTESTINAL CATARRH OF INFANCY. 

one year old, every three hours. I ordinarily employ it with double its 
quantity of subnitrate of bismuth, and know no better remedy for ordi- 
nary cases. The following is a convenient formula for administering 
substantially the same medicines in the liquid form : 

R. — Tinct. opii deodorat gtt. xvj. 

Bismuth, subnitrat zij 

Syr. simplic. . . . . . . . 5ss. 

Alistur. cretse ^iss. — Misce. 

Shake well and give one teaspoonful from three to four hours. 

In a large majority of cases I employ this prescription, or one similar 
to it, from my first visit. If the patient be not relieved by the opiate, 
alkali, and bismuth, and by proper regimen, in all probability inflamma- 
tion of the intestinal mucous membrane is present. In patients over 
the age of two or three years simple diarrhoea approaches in character 
that of the adult, and the treatment appropriate for the adult is proper 
in these cases, allowance being made for the diiference in age. In in- 
fants, in whom this disease, if protracted, is very liable to eventuate in 
spurious hydrocephalus, alcoholic stimulants are often required at an 
early period, on account of the prostration and feeble power of endur- 
ance. 



CHAPTER VIII. 

INTESTINAL CATARRH OF INFANCY (ENTERO-COLITIS). 

It is customary with writers to treat of inflammation of the small 
and large intestines in infancy as a single disease, for the following 
reasons : First, the symptoms of colitis at this period of life do not 
ordinarily differ, in any marked degree, from those of enteritis. The 
tormina, tenesmus, and abdominal tenderness, which characterize colitis 
in childhood and adult life, are ordinarily lacking, or are not appreciable 
by the observer; and the muco-sanguineous evacuations are oftener 
absent than present. On account of this absence of symptoms, Bou- 
chut says : " Dysentery is a very rare disease among young children. 
Its existence might even be denied, if it had not been observed at the 
period of some severe epidemics of dysentery." If Bouchut refers, by 
the term dysentery, to the ordinary phenomena of that disease, his re- 
mark is correct ; but, as regards the lesions, it is erroneous, for colitis 
is a common infantile malady. Billard, after analyzing eighty cases of 
intestinal inflammation in infants, says : "From this calculation, it is 
evidently very difficult to make a correct diagnosis of inflammation of 
the intestinal tube in sucking infants, yet it would seem as if the proper 
signs of enteritis or ileitis were the rapid tympanitis of the abdomen, 
the diarrhoea, accompanied with vomiting ; while in colitis, diarrhoea 



INTESTINAL CATARRH OF INFANCY. 



719 



alone, without tympanitis, is the most frequent." And again: "In 
consequence of the impossibility we have found to exist of tracing with 
exactitude the series of symptoms proper to inflammation of the differ- 
ent portions of the digestive tube, we shall content ourselves with pre- 
senting an analytical sketch of the causes, symptoms, and ordinary 
course of inflammation of the mucous membrane of the intestines in 
general." 

The frequent absence of any pathognomonic symptom or sign, by 
which to determine the exact seat of intestinal inflammation in the in- 
fant, is admitted by recent observers as well as Billard. 

The second reason why intestinal inflammation in the infant is de- 
scribed as a single disease is, that enteritis and colitis, in the majority of 
cases, coexist. This will be seen when we come to speak of the anatom- 
ical characters. 

In rural districts infantile diarrhoea is not so prevalent and fatal 
as in cities. In the farming sections it does not materially increase 
the death-rate, and it is, therefore, not so important a malady as in 
cities. In cities it largely increases the aggregate of deaths. Espe- 
cially fatal is that form of it which is known as the summer epidemic, 
as is seen by the mortuary records of any large city. Thus in New 
York City during 1882 the deaths from diarrhoea reported to the 
Health Board, tabulated in months, were as follows : 



Under five years. 
Over five vears 



Jan. Feb. Mar. Apr. May. June. July. Aug. Sept. Oct. Nov. Dec. 
34 32 50 50 72 231 1533 817 362 195 68 35 
14 15 14 20 15 19 131 149 84 55 31 24 



It is seen that in 1882 in New York City, the deaths from diarrhoea 
under the age of five years were greatly in excess of the number during 
the whole period of life subsequently to that age. 

The following statistics show how great a destruction of life this 
malady causes even under the surveillance of an energetic health board ; 
and before this board was established it was much greater, as I had 
abundant opportunities to observe. The last annual report of the New 
York Board of Health was made in 1875, since which time weekly 
bulletins have been issued. The deaths from diarrhoea at all a^es in 
the last three years in which annual reports were issued were as fol- 
lows : 

January 

February 

March 

April 

May . 

June 

July . 

August 

September 

October 

November 

December 



1873. 


1874. 


1875 


94 


43 


46 


84 


34 


52 


93 


40 


58 


114 


47 


45 


95 


61 


89 


220 


144 


157 


1514 


1205 


1387 


967 


1007 


1012 


424 


587 


608 


213 


255 


185 


. 87 


105 


57 


53 


56 


50 



In their annual report for 1870 the Board state : " The mortality 
from the diarrhoeal affections amounted to 2789, or 33 per cent, of the 



720 INTESTINAL CATARRH OF INFANCY. 

total deaths ; and of these deaths 95 per cent, occurred in children less 
than five years old, 92 per cent, in children less than two years old, and 
67 per cent, in those less than a year old." Every year the reports of 
the Health Board furnish similar statistics, but enough have been given 
to show how great a sacrifice of life infantile diarrhoea produces annu- 
ally in this city. 

What we observe in New York in reference to this disease is true 
also, to a greater or less extent, in other cities of this country and 
Europe, so far as we have reports. Not in every city is there the same 
proportionate mortality from this cause as in New York, but the fre- 
quency of infantile diarrhoea and the mortality which attends it render 
it an important disease in, I believe, most cities of both continents. In 
country towns, whether in villages or farm-houses, this disease is com- 
paratively unimportant, inasmuch as few cases occur in them, and the 
few that do occur are of mild type, and consequently much less fatal 
than in cities. 

The comparative immunity of rural districts has an important re- 
lation, as we will see, to the hygienic management of these cases. 

Etiology. — The diarrhoea of infants is occasionally produced by 
taking cold. Infants insufficiently protected by clothing, and exposed 
to sudden changes of temperature, or to currents of air in the apartments 
where they reside, or heedlessly exposed outdoor by careless nurses, 
sometimes become affected with diarrhoea, even of a fatal character. 
They contract an intestinal inflammation from taking cold, just as other 
infants may contract coryza or bronchitis from the same cause. 

But the most common causes of infantile diarrhoea are, first, the use 
of food which is unsuitable for infantile digestion, and which, therefore, 
acts as an irritant; and, secondly, residence in a foul atmosphere, to 
which we will soon call attention, and which largely increases the per- 
centage of deaths in our cities during the hot months. Diarrhoea due 
to taking cold occurs in all localities and climates, but it is obviously 
most common in times of changeable weather. That due to the use of 
unsuitable food and foul air, occurs for the most part in cities, and 
much more frequently in the summer season than in the cool months, 
as the above statistics show. Infantile intestinal catarrh, however pro- 
duced, presents nearly the same anatomical characters, so that, whatever 
its etiology, it is proper to describe it as one disease,, but that form of it 
which requires most elucidation, and the causes of which we will con- 
sider in the following pages, is that produced by impure air and im- 
proper diet. 

The prevalence and severity of infantile diarrhoea in cities, cor- 
respond closely with the degree of atmospheric heat, as may be inferred 
from the foregoing statistics. In New York this disease begins in the 
month of May — earlier in some years than in others — in a few scattered 
cases, commonly of a mild type. Cases become more and more numer- 
ous and severe as the weather grows warmer until July and August, 
w T hen the diarrhoea attains its maximum prevalence and severity. In 
these two months it is by far the most frequent and fatal of all the dis- 
eases in cities. In the middle of September new patients begin to be 
less common, and in the latter part of this month and subsequently new 



ETIOLOGY. 721 

cases do not occur, unless under unusual circumstances which favor the 
development of this malady. In New York a considerable number of 
deaths of infants occur from diarrhoea in October. October is not a 
hot month in our latitude — its average temperature is lower than that 
of May — and yet the mortality from this disease is considerably larger 
in the former than in the latter month. This fact, which seems to show 
that the prevalence of the summer diarrhoea does not correspond with 
the degree of atmospheric heat, is readily explained. The mortality in 
October, and indeed in the latter part of September, is not that of new 
cases, but is mainly of infants, as I have observed every year, who con- 
tract the disease in July or August or earlier, and linger in a state of 
emaciation and increasing weakness till they finally succumb, some even 
in cool weather. 

The fact is therefore undisputed, and is universally admitted, that the 
summer season, stated in a general way, is the cause of this annually 
recurring diarrhoeal epidemic, but it is not so easy to determine what 
are the exact causative conditions or agents which the summer weather 
brings into activity. That atmospheric heat does not in itself cause the 
diarrhoea is evident from the fact that in rural districts there is the 
same intensity of heat as in cities, and yet the summer complaint 
does not occur. The cause must be looked for in the state of the atmos- 
phere engendered by heat where unsanitary conditions exist, as in large 
cities. Moreover, observations show that the noxious effluvia with 
which the air becomes polluted under such circumstances constitute or 
contain the morbific agent. Thus, in one of the institutions of this city 
a few years since, on May 10, which happened to be an unusually warm 
day for this month, an offensive odor was noticed in the wards, which 
was traced to a large manure-heap that was being upturned in an adja- 
cent garden. On this day four young children were severely attacked 
by diarrhoea, and one died. Many other examples might be cited 
showing how the foul air of the city during the hot months, when animal 
and vegetable decomposition is most active, causes diarrhoea. Several 
years since, while serving as sanitary inspector for the Citizens' Asso- 
ciation in one of the city districts, my attention was particularly called 
to one of the streets, in which a house-to-house visitation disclosed the 
fact that nearly every infant between two avenues had diarrhoea, and 
usually in a severe form, not a few dying. This street was compactly 
built with wooden tenement-houses on each side, and contained a dense 
population, mainly foreigners, poor, ignorant, and filthy in their habits. 
It had no sewer, and the refuse of the kitchens and bed-chambers was 
thrown into the street, where it accumulated in heaps. Water trickled 
down over the sidewalks from the houses into the gutters or was thrown 
out as slops, so that it kept up a constant moisture of the refuse matter 
which covered the street, and promoted the decay of the animal and 
vegetable substances which it contained. The air in the domiciles and 
street under such conditions of impurity was necessarily foul in the 
extreme, and stifling during the hot days and nights of July and August ; 
and it was evidently the important factor in producing the numerous 
and severe diarrhoeal cases which were in these domiciles. 

In another locality, occupied by tripe-dealers and a low class of 

46 



722 INTESTINAL CATARRH OF INFANCY. 

butchers who carried on fat- and bone-boiling at night, the air was so 
foul after dark that the peculiar impurity which tainted it could be dis- 
tinctly noticed in the mouth for a considerable time after a night visit. 
In the street where these nuisances existed and in adjacent streets the 
summer diarrhoea was very prevalent and destructive to human life. 
Murchison states that twenty out of twenty-five boys were affected with 
purging and vomiting from inhaling the effluvia from the contents of an 
old drain near their school-room. Physicians are familiar with a similar 
fact showing this purgative effect of impure air — that the atmosphere of 
a dissecting-room often causes diarrhoea in those otherwise healthy. 

The exact nature of the deleterious agent or agents in foul air which 
cause the diarrhoea, whether they be gases or organisms, has not been 
fully determined ; but at a recent meeting of the Berliner Med. Gesell- 
schaft, A. Baginsky made a report on the bacilli of cholera infantum, 
which he states he has found both in the dejections and in the intestinal 
mucous membrane in the bodies of those who have perished with this 
disease. In the stools, along with numerous other organisms, Baginsky 
states that he found masses of zoogloea, and the same organisms he 
detected on the surface of the small intestines, and could trace their 
wanderings as far as the submucous tissue. 1 But it is evidently very 
difficult to determine whether such organisms sustain a causative rela- 
tion to diarrhoea or spring into existence in consequence of the foul 
secretions and decomposing fecal matters which are present. 

The impurities in the air of a large city are very numerous. Among 
those of a gaseous nature are sulphurous acid, sulphuric acid, sulphur- 
etted hydrogen ; various gases of the carbon group, as carbonic acid, 
carburetted hydrogen, and carbonic oxide ; gases of the nitrogen group, 
as the acetate, sulphide, and carbonate of ammonium, nitrous and nitric 
acids ; and at times compounds of phosphorus and chlorine (Parkes). 
A theory deserving consideration is that certain gaseous impurities 
found in the air form purgative combinations. D. F. Lincoln, in his 
interesting paper on the atmosphere in the Cyclopcedia of Medicine, 
writes in regard to sulphuretted hydrogen : " When in the air, freely 
exposed to the contact of oxygen, it becomes sulphuric acid. Sulphide 
of ammonium in the same circumstances becomes a sulphate, which, 
encountering common salt (chloride of sodium), produces sulphate of 
sodium and chloride of ammonium. The sulphates form a characteristic 
ingredient of the air in manufacturing districts." The sulphates, we 
know, are for the most part purgatives, but whether they or other 
chemical agents exist in the respired air in sufficient quantity to disturb 
the action of the intestines, even where atmospheric impurities are most 
abundant, is problematical and uncertain. 

Again, the solid impurities in the air of a large city are very numer- 
ous, as any one may observe by viewing a sunbeam in a darkened room, 
which is made visible by the numerous particles floating in it. These 
particles consist largely of organic matter, which sometimes has been 
carried a long distance by the wind. The remarkable statement has 
been made that in the air of Berlin organic forms have been found of 

1 Allegem. Wien. Mediz. Zeitung, Nov. 6, 1883. 



ETIOLOGY. 723 

African production. Ehrenberg discovered fragments of insects of vari- 
ous kinds — rhizopods, tardigrades, polygastrics, etc. — which, existing in 
considerable quantity and inhaled in hot weather, when decomposition 
and fermentation are most active, may be deleterious to the system. 
Monads, bacteria, vibriones, amorphous dust containing spores which 
retain their vitality for months, are among the substances found in the 
air of cities. The well-known hazy appearance of the atmosphere 
resting over a large city like New York when viewed from a distance is 
due to the gaseous and solid impurities with which the air is so abun- 
dantly supplied — impurities which assume importance in pathological 
studies, since minute organisms are now believed to cause so many dis- 
eases the etiology of which has heretofore been obscure. With our 
present knowledge- we must be content with the general statement that 
impure air is one of the two important factors which cause summer 
diarrhoea, without being able to state positively which of the elements 
in the air are most instrumental in causing this result. But the theory 
is plausible that minute organisms rather than chemical products are the 
chief cause. Henoch, of Berlin, writing upon this subject, calls atten- 
tion to the disease known as intestinal mycosis, its prominent symptom 
being a severe diarrhoea produced by eating diseased meat containing a 
fungus. He believes that " a portion of the fungus not destroyed by 
the gastric juice settles upon different parts of the intestine, and there 
produces its effects ;" and he adds, "At present, however, we can regard 
the mykotic theory of cholera infantum only as a very probable hypoth- 
esis. There is no doubt that high atmospheric temperature increases 
the tendency to fermentation dyspepsias which is present in imperfectly 
nourished children at all seasons, and causes them to appear not only 
epidemically, but also in an extremely acute form which is not frequent 
under ordinary circumstances. This would lead to the conclusion that. 
in addition to the heat, infectious germs are present, which, being devel- 
oped in great masses by the former, enter the stomach with the food." 
The fungus theory of the causative relation of atmospheric heat to the 
diarrhoea of the summer season, as thus explained by Henoch, commands 
the readier assent since.it comports with the well-known facts relating 
to the etiology of the summer complaint. This disease, as we have seen, 
is most prevalent and fatal under precisely those conditions of dense 
population, filthy domiciles and streets, and atmospheric heat which are 
favorable for the development of low organisms. 

In those portions of our cities which are occupied by the poor, more 
than anywhere else, those conditions prevail which render the atmos- 
phere deleterious. One accustomed to the pure air of the country 
would scarcely believe how stifling and poisonous the atmosphere be- 
comes during the hot summer days and close summer nights in and 
around the domiciles in the poor quarters of the city. Among the causes 
of this foul air may be mentioned too dense a population, the occupancy 
of small rooms by large families, rigid economy and ceaseless endeavor 
to make ends meet, so that in the absorbing interest sanitary require- 
ments are sadly neglected. Adults of such families, and children of 
both sexes as soon as they are old enough, engage in laborious and often 
filthy occupations. Many of them seldom bathe, and they often wear 



724 INTESTINAL CATARRH OF INFANCY. 

for days the same undergarments, foul with perspiration and dirt. The 
intemperate, vicious, and indolent, who always abound in the quarters 
of the city poor, are notoriously filthy in their habits and add to the 
insalubrity by their presence. Children old enough to be in the 
streets and adults away at their occupations escape to a great extent 
the evil effects of impure air, but the infantile population always suffer 
severely. 

Every physician who has witnessed the summer diarrhoea of infants is 
aware of the fact that the mode of feeding has much to do with its occur- 
rence. A large proportion of those who each summer fall victims to it 
would doubtless escape if the feeding were exactly proper. In New 
York City facts like the following are of common occurrence in the 
practice of all physicians : Infants under the age of eight months, if 
bottle-fed, nearly always contract diarrhoea, and usually of an obstinate 
character, during the summer months. The younger the infant, the 
less able is it to digest any other food than breast-milk, and the more 
liable is it therefore to suffer from diarrhoea if bottle-fed. In the insti- 
tutions nearly every bottle-fed infant under the age of four or even six 
months dies in the hot months with symptoms of indigestion and intes- 
tinal catarrh, while the wet-nursed of the same ages remain well. 
Sudden weaning, the sudden substitution of cow's milk or any artifi- 
cially prepared food in place of breast-milk in hot weather, almost always 
produces diarrhoea, often of a severe and fatal nature. Feeding an infant 
in the hot months with indigestible and improper food, as fruits with 
seeds or the ordinary table food prepared in such a way that it over- 
taxes the digestive function of the infant, causes diarrhoea, and not in- 
frequently that severe form of it which will be described under the term 
cholera infantum. Many obstinate cases of the summer complaint begin 
to improve under change of diet, as by the substitution of one kind of 
milk for another or the return of the infant to the breast after it has 
been temporarily withdrawn from it. It is a common remark in the 
families of the city poor that the second summer is the period of greatest 
danger to infants. This increased liability of infants to contract diar- 
rhoea in the second summer is due to the fact that most infants in their 
second year are table-fed, while in the first year they are wet-nursed. 
Such facts, with which all physicians are familiar, show how important 
the diet is as a factor in causing the summer complaint. 

Occasionally, from continued ill-health, the milk of the mother or 
wet-nurse does not agree with the nursling. Examined with the micro- 
scope, it is found to contain colostrum. Under such circumstances if a 
healthy wet-nurse be employed the diarrhoea ceases. It is very im- 
portant that any woman furnishing breast-milk to an infant should lead 
a quiet and regular life, with regular meals and sleep. R. B. Gilbert 1 
relates striking cases in which venereal excesses on the part of wet- 
nurses were immediately followed by fatal diarrhoea in the infants which 
they suckled. 

One not a resident would scarcely be able to appreciate the difficulty 
which is experienced in a large city in obtaining proper diet for young 

1 Louisville Med. Journal, Aug. 19, 1882. 



ETIOLOGY. 725 

children, especially those of such an age that they require milk as the 
basis of their food. Milk from cows stabled in the city or having a 
limited pasturage near the city, and fed upon a mixture of hay with 
garden and distillery products, the latter often largely predominating, is 
unsuitable. It is deficient in nutritive properties, prone to fermenta- 
tion, and from microscopical and chemical examinations which have 
been made it appears that it often contains deleterious ingredients. If 
milk be obtained from distant farms where pasturage is fresh and abun- 
dant — and in New York City this is the usual source of the supply — 
considerable time elapses before it is served to customers, so that, par- 
ticularly in the hot months of July and August, it frequently has begun 
to undergo lactic acid fermentation when the infants receive it. That 
dispensed to families in the morning is the milking of the previous 
morning and evening. The use of this milk in midsummer by infants 
under the age of ten months frequently gives rise to more or less 
diarrhoea. 

The ill-success of feeding with cow's milk has led to the preparation 
of various kinds of food which the shops contain, but no dietetic prepa- 
ration has yet appeared w T hich agrees so w T ell with the digestive function 
of the infant as breast-milk, and is at the same time sufficiently nutritive 

In New York City improper diet, unaided by the conditions which 
hot weather produces, is a common cause of diarrhoea in young infants, 
for at all seasons we meet with this diarrhoea in infants who are bottle- 
fed; but when the atmospheric conditions of hot weather and the use 
of food unsuitable for the age of the infant are both present and opera- 
tive, this diarrhoea . so increases in frequency and severity that it is 
proper to designate it the summer epidemic of the cities. Several years 
since, before the New York Foundling Asylum was established, the 
foundlings of New York, more than a thousand annually, were taken 
to the almshouse on Blackwell's Island and consigned to the care of 
pauper- women, who were mostly old, infirm, and filthy in their habits 
and apparel. Their beds, in which the foundlings were also placed 
alongside of them, were seldom clean, not properly aired and washed, 
and under the beds were various garments and utensils which these 
pauper-women had brought with them as their sole property from their 
miserable abodes in the city. With such surroundings, the air which 
these infants breathed day and night manifestly contained poisonous ema- 
nations ; while their diet was equally improper, for it was prepared by 
these women from such milk and farinaceous food as w T ere furnished the 
almshouse. When assigned to duty in the almshouse, this service being 
at that time a branch of Charity Hospital, I was informed that all the 
foundlings died before the age of two months ; one only was pointed out 
as a curiosity which had been an exception to the rule. The disease of 
which they perished was diarrhoea, and this malady in the summer 
months was especially severe and rapidly fatal. The unpleasant experi- 
ences in this institution furnished additional evidence, Were any wanting, 
that foul air and improper diet are the two important factors in causing 
the summer diarrhoea of infants. Since that beneficial charity, the New 
York Foundling Asylum, in East Sixty-eighth Street, came into exist- 



726 INTESTINAL CATARRH OF INFANCY. 

ence, providing pure air and, for a considerable proportion of the found- 
lings, breast-milk, many of these waifs have been rescued from death. 

Age. — Age is a predisposing cause of diarrhoea, since most cases 
occur under the age of three years. A large majority of the summer 
diarrhoeas of the cities occur under the age of two years. The following 
table embraces all the cases that came to one of the city dispensaries 
during .my service between the months of May and October, inclusive : 

Age. Cases. 



5 months or under 

5 months to 12 months 

12 months to 18 months 

18 months to 24 months 

24 months to 36 months 



58 

212 

174 

93 

36 



Total. . 573 

Dentition. — Statistics show that by far the largest number of cases 
occur during the period of first dentition ; hence the prevalent opinion 
among families that dentition causes the diarrhoea. It is the common 
belief among the poor of New York that diarrhoea occurring during 
dentition is conservative, and should not be checked. They believe that 
an infant cutting its teeth suffers less, and may be saved from serious 
illness, if it have frequent stools. Every summer I see infants reduced to 
a state of imminent danger through the continuance of diarrhoea during 
several weeks, nothing having been done to check it in consequence of this 
absurd belief. The progressive loss of flesh and strength and wasting 
of the features do not excite alarm, under the blinding influence of this 
theory, till the diarrhoea has continued so long and become so severe 
that it is with difficulty controlled, and the patient is in a state of real 
danger when the physician is first summoned. The following statistics, 
which comprise cases occurring during my service in one of the city 
dispensaries, show the preponderance of cases during the age when 
dental evolution is occurring : 

Cases. 
No teeth and no marked turgescence of gums .... 47 

Cutting incisors . . 106 

Cutting anterior molars ........ 41 

Cutting canines .......... 40 

Cutting last molars . . . . . . ... .20 

All the teeth cut 28 

Total 282 

It so happens that the period of dental evolution corresponds with 
that of the most rapid development and the greatest functional activity 
of the gastric and intestinal follicles, and the predisposition which exists 
to diarrhoeal maladies at this age must be attributed to this cause rather 
than to dentition. 

Symptoms. — The intestinal catarrh of infancy commonly begins 
gradually with languor, fretfulness, and slight febrile movement. The 
diarrhoea at first usually attracts little attention from its mildness. The 
stools, while they are thinner than natural, vary in appearance, being 
yellow, brown, or green. Infants with milk diet usually pass green 



SYMPTOMS. 727 

and acid stools containing particles of undigested casein. The tongue 
in the commencement of the attack is moist and covered with a slight 
fur. At a more advanced stage it may be moist, but is often dry, and 
in dangerous forms of the malady, accompanied by prostration, the 
buccal surface is red and the gums more or less swollen and sometimes 
ulcerated. Vomiting is common. It may commence simultaneously 
with the diarrhoea, especially when food that is unusually indigestible 
and irritating to the stomach has been given, but more frequently this 
symptom does not appear until the diarrhoea has continued a few days. 
I preserved memoranda of the date when vomiting began in the cases 
treated in two consecutive years, and found that ordinarily it was 
toward the close of the first week. When it is an early and prominent 
symntom it appears to be due to the presence in the stomach of imper- 
fectly digested or fermented and acid food, which, when ejected, gives a 
decidedly acid reaction with appropriate tests. It contains coagulated 
casein and undigested particles of whatever food has been given. In 
many patients the progressive loss of flesh and strength is largely due 
to the indigestion and vomiting by which the food, which is so much re- 
quired for proper nourishment, is lost. 

Emesis occurring at a late stage of infantile diarrhoea is often due to 
commencing spurious hydrocephalus, which is not an infrequent com- 
plication, as we will see, of protracted cases. Perhaps when a late symp- 
tom it may sometimes have an uremic origin, for the urine is usually 
quite scanty in advanced cases. It seems probable, however, that dele- 
terious effects from non-elimination of urea are to a considerable extent 
prevented by the diarrhoea. 

The fecal evacuations may remain nearly uniform in appearance 
during the disease, but in many patients they vary in color and con- 
sistence at different periods. In the same case they may be brown and 
offensive at one time, green at another, and again they may contain 
masses of a putty-like appearance, the partly digested casein or altered 
epithelial cells. The stools sometimes consist largely of mucus, with 
or without occasional streaks of blood, indicating the predominance of 
inflammation in the colon. This is the mucous diarrhoea qf Barrier. 
The stools are sometimes yellow when passed, but become green on ex- 
posure to the air from chemical reaction due to admixture with the urine. 

The character of the alvine discharges is interesting. In addition to 
undigested casein I have found epithelial cells, single or in clusters 
(sometimes regularly arranged as if detached in mass from the villi), 
fibres of meat, crystalline formations, mucus, and occasionally blood, as 
stated above. In one instance I observed an appearance resembling 
three or four crypts of Lieberklihn united, probably thrown off by 
ulceration. If the stools are green, colored masses of various sizes, but 
mostly small, are also seen under the microscope. 

The pulse is accelerated according to the severity of the attack. The 
heat of the surface is at first generally increased, though but slightly in 
ordinary cases ; but when the vital powers begin to fail from the con- 
tinuance of the diarrhoea the warmth of the surface diminishes. In 
advanced cases approaching a fatal termination the face and extremities 
are pallid and cool, and the pulse gradually becomes more frequent and 



728 INTESTINAL CATARRH OF INFANCY. 

feeble. The skin is usually dry, and, as already stated, the urinary 
secretion diminished. In severe cases attended by frequent alvine dis- 
charges the infant does not pass urine oftener than once or twice daily. 
The imperfect action of the skin and kidneys is noteworthy. 

Protracted cases of diarrhoea are frequently complicated by two cuta- 
neous eruptions — erythema extending over the perineum and frequently 
as far as the thighs and lower part of the abdomen, due to the acid and 
irritating character of the stools ; and boils upon the forehead and scalp. 
The latter sometimes extend to the pericranium, and in case of recovery 
leave permanent cicatrices. This furuncular affection of the scalp has 
seemed to me useful in consequence of the external irritation which it 
causes, since it occurs at a time when, on account of the feeble heart's 
action and languid circulation, passive congestion of the vessels of the 
brain and meninges is liable to be present. 

Patients who are weak and wasted in consequence of protracted diar- 
rhoea, remaining almost constantly in the recumbent position, often have 
an occasional dry cough which continues till the close of life. It is due 
to hypostatic congestion in the lungs, usually limited to the posterior 
and inferior portions of the lobes, extending but a little way into the 
lungs. It is the result of prolonged recumbency with feeble heart's 
action and feeble pulmonary circulation. Infants reduced by chronic 
diseases, lying day after day in their cribs with little movement of their 
bodies, are very liable to this passive congestion of depending portions 
of their lungs, toward which the blood gravitates, and into which but 
little air enters in consequence of their distance and position and the 
feeble respirations. The hyperemia which results is of a passive char- 
acter, a venous congestion, and the affected lobules have a dusky-red 
color. This congestion, continuing, soon results in pneumonitis of the 
catarrhal form, subacute and of a low grade, for pulmonary lobules in 
which the blood remains stagnant soon exhibit augmented cell-prolifera- 
tion, perhaps from the irritating effects of the elements of the blood now 
withdrawn from the circulation. 

I have made or procured a considerable number of microscopic exami- 
nations in .these cases of hypostatic pneumonia, and the solidification of 
the pulmonary lobules has been found to be due to the exaggerated de- 
velopment of the epithelial cells in the alveoli, together with venous 
congestion. The affected lobules, whether in a stage 'of hypostatic con- 
gestion or the more advanced stage of hypostatic pneumonitis, when 
examined at the autopsy, were somewhat softer than in health, of dark 
color, and many of the lobules could be inflated by strong force of the 
breath ; but in protracted cases the alveoli in central parts of the 
inflamed area resisted insufflation. The lung in hypostatic pneumonia, 
even when it is inflated, still feels firmer between the fingers than the 
normal lung. 

Hypostatic pneumonia is so common in hospitals for infants that some 
physicians whose observations have been chiefly in such institutions 
have almost ignored other forms of pulmonary inflammation. Billard, 
many years ago, wrote : " . . . . The pneumonia of young chil- 
dren is evidently the result of stagnation of blood in their lungs. 
Under these circumstances the blood may be regarded as a kind of 



SYMPTOMS. 729 

foreign body." Of all the chronic and exhausting diseases of infancy, 
no one has, according to my observations, been so frequently compli- 
cated by hypostatic pneumonia as the disease which we are considering, 
although it does not usually give rise to any more prominent symptom 
than an occasional cough. Limited to a small and almost immovable 
part of the lung, it does not ordinarily accelerate respiration or render 
it painful, and the cough is also apparently painless. 

When progressive loss of flesh and strength has continued several 
weeks, and the patient is much exhausted, another complication is liable 
to occur, known as spurious hydrocephalus or the hydrocephaloid dis- 
ease, the anatomical characters of which will be described in the proper 
place. The commencement of spurious hydrocephalus is announced by 
gradually increasing drowsiness, perhaps preceded by a period of unusual 
fretfulness. Vomiting and rolling the head are occasional early symp- 
toms of this complication. As the drowsiness increases the pupils 
become less sensitive to light than in their normal state, and are usually 
contracted. When the drowsiness becomes profound and constant, the 
pupils remain contracted as in sound sleep or in opium narcotism. The 
functional activity of the organs is now also diminished, the vomiting 
ceases, the stools become less frequent, the buccal surface dry, and the 
urine scanty, while the pulse is frequent and feeble. Spurious hydro- 
cephalus either continues till death, or by stimulation the patient may 
emerge from it. When profound the usual result is death. 

Although infantile diarrhoea in its commencement may be promptly 
arrested by proper hygienic and medicinal treatment, if it continue a 
few weeks the anatomical changes which occur are such that recovery, 
if it take place, is necessarily slow and gradual. Improvement is shown 
by better digestion, fewer stools, and of better appearance, less frequent 
vomiting, a more cheerful countenance, and the absence of symptoms 
which indicate a complication. Many recover after days of anxious 
watching and perhaps after many fluctuations. 

Death may occur early from a sudden aggravation of symptoms and 
rapid sinking, or the attack may be so violent from the first that the 
infant quickly succumbs ; but more frequently death takes place after a 
prolonged sickness. Little by little the patient loses flesh and strength, 
till a state of marked emaciation is reached. The eyes and cheeks are 
sunken, the bony projections of the face, trunk, and limbs become prom- 
inent, and the skin lies in wrinkles from the wasting. The altered 
expression of the face makes the patient look older than the actual age. 
The joints in contrast with the wasted extremities seem enlarged and the 
fingers and toes elongated. The stools diminish in frequency from 
diminished peristaltic and vermicular action, and vomiting, if previously 
present, now ceases. A feeble, quick, and scarcely appreciable pulse, 
slow respiration, and diminished inflation of the lungs, sightless and 
contracted pupils, over which the eyelids no longer close, announce 
the near approach of death. The drowsiness increases and the limbs 
become cool, while perhaps the head is hot. The infant no longer has 
the ability to nurse, or if bottle-fed the food placed in the mouth flows 
back, or is swallowed with apparent indifference. So low is its vitality 
that it lies pallid and almost motionless for hours or even days before 



730 INTESTINAL CATARRH OF INFANCY. 

death, and death occurs so quietly that the moment of its occurrence is 
scarcely ap] >reciable. 

Anatomical Characters. — Since the prominent and essential 
symptoms of the disease which we are considering pertain to the diges- 
tive apparatus, it is evident that the lesions which attend and charac- 
terize it are to be found in this part of the system. Lesions elsewhere, 
so far as they are appreciable to us, are secondary and not essential. 
I have witnessed a large number of autopsies of infants who have per- 
ished from diarrhoea, chiefly in institutions, and they have been suf- 
ficiently marked and uniform to enable us to designate it an entero- 
colitis. Several years since I preserved records of the autopsical 
appearances in the intestinal catarrh of infants, most of the cases being 
of summer diarrhoea. The number aggregated eighty-two. Since 
then I have witnessed many autopsies in institutions in cases of this 
disease, and the lesions observed were similar to those in the eighty-two 
cases. 

The question may properly be asked, Can inflammatory hyperemia 
of the intestinal mucous membrane be distinguished from simple con- 
gestion if there be no ulceration and no appreciable thickening of the 
intestine ? It is possible that occasionally I have recorded as inflamma- 
tory what was simply a congestive lesion, but I do not think I have in- 
corporated a sufficient number of such cases to vitiate the statistics. In 
a large proportion of the cases there was evident thickening of the in- 
testinal mucous membrane or other unequivocal evidence of inflamma- 
tion. The following is an analysis of the eighty-two cases : 

The duodenum and jejunum presented the appearance of inflammatory 
hyperemia in 12 cases. The hypereemia was usually in patches of 
variable extent or of that form described by the term arborescent. In 
51 cases the duodenal and jejunal mucous membrane was pale and with- 
out any other appearance characteristic of catarrh or inflammation. In 
the remaining 19 cases the appearance of the duodenum and jejunum 
was not recorded, so that it was probably normal. On the other hand, 
in the ileum inflammatory lesions were present as a rule. In 49 cases I 
found the surface of the ileum distinctly hyperaemic, and in that portion 
of it nearest the ileo-csecal valve, including the valve itself, the inflam- 
mation had evidently been the most intense, since in this portion the 
hyperemia and thickening of the mucous membrane were most marked. 
In 16 cases the surface of the ileum appeared nearly or quite normal ; 
in 14 hyperemia in the small intestines in patches, streaks, or arbo- 
rescence was recorded, but the records do not state in which division of 
the intestines they were observed. 

Billard, with other observers, has noticed the frequency and intensity 
of the inflammatory lesions in entero-colitis in the terminal portion of 
the small intestines, and the thickening in many cases of the ileo-csecal 
valve, and he asks whether the vomiting which is so common and often 
obstinate in this disease may not be sometimes due to obstruction to the 
passage of fecal matter at the valve in consequence of the hypersemia 
and swelling, but has not observed any retained fecal matter above it, 
such as we find in any part of the colon, or any other appearance which 
indicated sufficient obstruction to cause symptoms. Still, it seems not 



ANATOMICAL CHARACTERS. 731 

improbable that the reason why the inflammatory lesions are more pro- 
nounced at and immediately above the valve than in other parts of the 
small intestine is that the fecal matter, so commonly acid and irritating 
in this disease, is somewhat delayed in its passage downward at this point. 

Small superficial circular or oval ulcers were observed in the ileum in 
4 cases, in 2 of which they w T ere found also in the lower part of the 
jejunum. In 1 case the records state that ulcers were in the jejunum, 
but do not mention whether they were also in the ileum. In 1 case, in 
which there was much thickening of the ileum next to the ileo-caecal 
valve, many small granulations had sprouted up from the submucous 
connective tissue, so that the mucous surface appeared as if studded w T ith 
small warts. 

Softening of the mucous membrane was also apparent in certain cases. 
The firmness of its attachment to the parts underneath varied consider- 
ably in different specimens. I was able in cases in which there was 
considerable softening to detach readily the mucous membrane w T ith the 
nail or handle of the scalpel within so short a period after death that it 
was probable that the change of consistence was not cadaveric. In some 
cases the vessels of the submucous tissue were injected and this tissue 
infiltrated. 

In all the cases except one lesions were present indicating inflammation 
of the mucous membrane of the colon. In 39 hyperemia, thickening, 
and other signs of inflammation extended over nearly or quite the entire 
colon ; in 14 the colitis was confined to the descending portion entirely 
or almost entirely ; in 28 cases the records state that inflammatory 
lesions were found in the colon, but their exact location is not men- 
tioned. In 18 of the autopsies the 'mucous membrane of the colon was 
found ulcerated. 

Therefore, according to these statistics — and autopsies which I have 
witnessed that are not embraced in them disclosed similar lesions — 
colitis is present, almost without exception, in cases of summer diar- 
rhoea, associated with more or less ileitis. The portion of the colon 
w T hich presents the most marked inflammatory lesions is that in and 
immediately above the sigmoid flexure — that portion, therefore, in 
which any fermenting fecal matter has reached its greatest degree of 
fermentation, and consequently contains the most irritating elements, 
and where, next to the caput coli, it is longest delayed in its passage 
downward. 

The solitary glands of both the large and small intestines and Peyer's 
patches undergo hyperplasia. In cases of short duration, and in parts 
of the intestine where the inflammatory action has been mild, the solitary 
glands present a vascular appearance, like the surrounding membrane, 
and are slightly enlarged. The enlargement is most apparent if the 
intestine be view r ed by transmitted light, when not only are the glands 
seen to be swollen, but their central dark points are distinct. If a 
higher grade of intestinal catarrh or a catarrh more protracted have 
occurred, the volume of these follicles is so increased that they rise 
above the common level and present a papillary appearance. Peyer's 
patches are also distinct and punctate. The enlargement of Peyer's 



732 INTESTINAL CATARRH OF INFANCY. 

patches, like that of the solitary glands, is due to hyperplasia, the ele- 
mentary cells being largely increased in number. 

The small ulcers which, as we have seen from the above statistics, are 
present in a certain proportion of cases in the mucous membrane of the 
colon, and more rarely in that of the small intestine when the inflam- 
mation has been protracted and of a severe type, appear to occur in the 
solitary glands and in the mucous membrane surrounding them. While 
some of these glands in a specimen are simply tumefied, others are 
slightly ulcerated, and others still nearly or quite destroyed. The ulcers 
are usually from one to three lines in diameter, circular or oval, with 
edges slightly raised from infiltration. Rarely, I have seen minute 
coagula of blood in one or more ulcers, and I have also observed ulcers 
which have evidently been larger and have partially healed. The ulcers 
are more frequently found in the descending colon than in other por- 
tions of the intestines. When ulcers are present they commonly occur 
in the descending colon, or if occurring elsewhere they are most abun- 
dant in this situation. 

According to my observations, these ulcers are found chiefly in infants 
over the age of six months — during the time, therefore, when there is 
greatest functional activity and most rapid development of the solitary 
glands. Peyer's patches, though frequently prominent and distinct, 
have not been ulcerated in any of the cases observed by me. 

The appendix vermiformis participates in the catarrh when it occurs 
in the caput coli, its mucous membrane being hyperaemic and thickened. 
In certain rare cases the inflammation is so intense that a thin film of 
fibrin is exuded in places upon the surface of the colon. It is liable to 
be overlooked or washed away in the examination. The rectum usually 
presents no inflammatory lesions, or but slight lesions in comparison 
with those in the colon. It remains of the normal pale color, or is but 
slightly vascular in most patients, even when there is almost general 
colitis. Hence the infrequency of tenesmus. 

As might be expected from the nature of the disease, the secretion 
of mucus from the intestinal surface is augmented. It is often seen 
forming a layer upon the intestinal surface, and it appears in the stools 
mixed with epithelial cells and sometimes with blood and pus. 

The mesenteric glands in cases which have run the most protracted 
course and ended fatally are found more or less enlarged from hyper- 
plasia. They are frequently as large as a pea or larger, and of a light 
color, the color being due not only to the hyperplasia, but in part to the 
anaemia. Occasionally, when patients have been much reduced from 
the long continuance of the diarrhoea, and are in a state of marked 
cachexia before death, we find certain of these glands caseous. 

The state of the stomach is interesting, since indigestion and vomiting 
are so commonly present. I have records of its appearance in 59 cases, 
in 42 of which it seemed normal, having the usual pale color and ex- 
hibiting only such changes as occur in the cadaver. In the remaining 
17 cases the stomach was more or less hyperaemic, and in 3 of them 
points of ulceration were observed in the mucous membrane. 

All physicians familiar with this disease have remarked the fre- 
quency of stomatitis. In protracted and grave cases it is a common 



ANATOMICAL CHARACTERS. 733 

complication. The buccal surface in these cases is more vascular than 
natural, and if the vital powers are much reduced superficial ulcerations 
are not infrequent, cftener upon the gums than elsewhere. The gums 
are frequently spongy, more or less swollen, bleeding readily when 
rubbed or pressed upon. Thrush is a common complication of pro- 
tracted diarrhoea in infants under the age of three or four months, but 
is infrequent in older infants. Occurring in those over the age of six 
or eight months, it has an unfavorable prognostic significance, indi- 
cating a form of diarrhoea which commonly eventuates in death. 

The belief has long been prevalent in the past that the liver is also 
in fault. The green color of the stools was supposed to be due to viti- 
ated bile. But usually in the post-mortem examinations which I have 
made I have found that the green coloration of the fecal matter did 
not appear at the point where the bile enters the intestines, but at some 
point below the ductus communis choledochus in the jejunum or ileum. 
The green tinge, at first slight, becomes more and more distinct on 
tracing it downward in the intestine. It appears to be due to admix- 
ture of the intestinal secretions with the fecal matter. 

I have notes of the appearance and state of the liver in 32 fatal 
cases. Nothing could be seen in these examinations which indicated 
any anatomical change in this organ that could be attributed to the 
diarrhceal malady. The size and weight of the liver varied consider- 
ably in infants of the same age, but probably there was no greater dif- 
ference than usually obtains among glandular organs in a state of 
health. The following was the weight of this organ in 20 cases : 

Age. Weight. Age. Weight. 

4 weeks 5 ounces. 10 months 6 J ounces. 

2 months 3| " 13 " ...... 6 

2 •» 3| < 14 « 9 

4 " 5 " 15 " 6 

5 «« 6J 15 " 7J 

5 " 9 " 15 " 9£ 

7 " 4J 16 << 6" 

7 " 6 " 19 " 4£ 

7 " 6i » 20 " 9j 



23 " ...... 15 



In none of these cases did the size, weight, or appearance of this organ 
seem to be different from that in health or in other diseases, except in 
one in which fatty degeneration had occurred, but this was probably 
due to tuberculosis, which was also present. In most of these cases the 
liver was examined microscopically, and the only noteworthy appear- 
ance observed was the variable amount of oil-globules in the hepatic 
cells. In some specimens the oil-globules were in excess, in others 
deficient, and in others still they were more abundant in one part of the 
organ than in another. Little importance was attached to these differ- 
ences in the quantity of oily matter. 

Hypostatic congestion of the posterior portions of the lungs, ending 
if it continue in a form of subacute catarrhal pneumonia and giving 
rise to an occasional painless cough, has been described in the preced- 
ing pages. The character of the cough in connection with the wasting 
might excite suspicions of the presence of tubercles in the lungs ; but 



734 INTESTINAL CATARRH OF INFANCY. 

tubercles are rare in this disease, and when present I should suspect a 
strong hereditary predisposition. They occurred in only 1 of the 82 cases. 

The state of the encephalon in those patients in whom spurious 
hydrocephalus occurs is interesting. In protracted cases of diarrhoea 
the brain wastes like the body and limbs. In the young infant, in 
whom the cranial bones are still ununited, the occipital and sometimes 
the frontal bones become depressed and overlapped by the parietal, the 
depression being of course proportionate to the diminution in size of the 
encephalon. The cranium becomes quite uneven. In other children, 
with the cranial bones consolidated, serous effusion occurs according to 
the degree of waste, thus preserving the size of the encephalon. The 
effusion is chiefly external to the brain, lying over the convolutions from 
the base to the vertex. Its quantity varies from one or two drachms to 
an ounce or more. Along with this serous effusion, and antedating it, 
passive congestion of the cerebral veins and sinuses is also present. 
This congestion is the obvious and necessary result of the feebleness of 
the heart's action and the loss of brain substance. 

Diagnosis. — In the adult abdominal tenderness is an important 
diagnostic symptom of intestinal catarrh, but in the infant this symptom 
is lacking or is not in general appreciable, so that it does not aid in 
diagnosis. When the diagnosis of the disease is established, the symp- 
toms do not usually indicate what part of the intestinal surface is chiefly 
involved, but it may be assumed that it is the lower part of the ileum 
and the colon. The presence of mucus or of mucus tinged with blood 
in the stools shows the predominance of colitis. 

Prognosis. — Although this disease largely increases the death-rate 
of young children, most cases can be cured if proper hygienic and 
medicinal measures be early applied. It is obvious, from what has 
been stated in the foregoing pages, that cholera infantum is the form 
of this malady which involves greatest danger. Except in such cases 
there is sufficient forewarning of a fatal result, for if death occur it is 
after a lingering sickness, with fluctuations and gradual loss of flesh 
and strength. Patients often recover from a state of great prostration 
and emaciation, provided that no fatal complications arise. The eyes 
may be sunken, the skin lie in folds from the wasting, the strength may 
be so exhausted that any other than the recumbent position is impos- 
sible, and yet the patient may recover by removal 'to the country, by 
change of weather, or by the use of better diet and remedies. There- 
fore an absolutely unfavorable prognosis should not be made except in 
cases that are complicated or that border on collapse. The most dan- 
gerous symptoms, except those which indicate commencing or actual 
collapse, arise from the state of the brain. Rolling the head, squinting, 
feeble action or permanent contraction of the pupils, spasmodic or 
irregular movements of the limbs, indicate the near approach of death, 
as do also coldness of face and extremities and inability to swallow. It 
is obvious also, in making the prognosis in ordinary cases, that we 
should consider the age of the patient, and if the diarrhoea be that of the 
summer season, the state of the weather, the time in the summer, whether 
in the beginning or near its close, and the surroundings, especially in 
reference to the impurity of the air, as well as the patient's condition. 



CHOLERA INFANTUM. 735 



Cholera Infantum, or Choleriform Diarrhoea. 

This is the most severe form of infantile diarrhoea. It receives the 
name which designates it from the violence of its symptoms, which 
closely resemble those of Asiatic cholera. It is, however, quite distinct 
from that disease. It is characterized by frequent stools, vomiting, 
great elevation of temperature, and rapid and great emaciation and loss 
of strength. It commonly occurs under the age of two years. It some- 
times begins abruptly, the previous health having been good ; in other 
cases it is preceded by the ordinary form of diarrhoea. The stools have 
been thinner than natural and somewhat more frequent, but not such as 
to excite alarm, when suddenly they become more frequent and watery, 
and the parents are surprised and frightened by the rapid sinking and 
real danger of the infant. 

The first evacuations, unless there have been previous diarrhoea, may 
contain fecal matter, but subsequently they are so thin that they soak 
into the diaper like urine, and in some cases they scarcely produce more 
of a stain than does this secretion. Their odor is peculiar — not fecal, 
but musty and offensive ; occasionally they are almost odorless. Com- 
mencing simultaneously with the watery evacuations, or soon after, is 
another symptom, irritability of the stomach, which increases greatly the 
prostration and danger. Whatever drinks are swallowed by the infant 
are rejected immediately or after a few moments, or retching may occur 
without vomiting. The appetite is lost and the thirst is intense. Cold 
water is taken with avidity, and if the infant nurse, it eagerly seizes the 
breast in order to relieve the thirst. The tongue is moist at first, and clean 
or covered with a light fur, pulse accelerated, respiration either natural 
or somewhat increased in frequency, and the surface warm, but the tem- 
perature is speedily reduced in severe cases. The internal temperature 
or that of the blood is always very high. In ordinary cases of cholera 
infantum the thermometer introduced into the rectum rises to or above 
105°, and I have seen it indicate 107°. Although the infant may be 
restless at first, it does not appear to have any abdominal pain or ten- 
derness. The restlessness is apparently due to thirst or to that un- 
pleasant sensation which the sick feel when the vital powers are rapidly 
reduced. The urine is scanty in proportion to the gravity of the attack, 
as it ordinarily is when the stools are frequent and watery. 

The emaciation and loss of strength are more rapid than in any other 
disease which I can recall to mind, unless in Asiatic cholera. In a few 
hours the parents scarcely recognize in the changed and melancholy 
aspect of the infant any resemblance to the features which it exhibited 
a day or two before. The eyes are sunken, the eyelids and lips are 
permanently open from the feeble contractile power of the muscles 
which close them, while the loss of the iluids from the tissues and the 
emaciation are such that the bony angles become more prominent and 
the skin in places lies in folds. 

As the disease approaches a fatal termination, which often occurs in 
two or three days, the infant remains quiet, not disturbed even by the 



736 CHOLERA INFANTUM. 

flies which alight upon its face. The limbs and face become cool, the 
eyes bleared, pupils contracted, and the urine scanty or suppressed. In 
some instances, -when the patient is near death, the respiration becomes 
accelerated, either from the effect of the disease upon the respiratory 
centres or from pulmonary congestion resulting from the feeble circula- 
tion. As the vital powers fail the pulse becomes progressively more 
feeble, the surface has a clammy coldness, the contracted pupils no 
longer respond to light, and the stupor deepens, from which it is impos- 
sible to arouse the infant. 

In the more favorable cases cholera infantum is checked before the 
occurrence of these grave symptoms, and often in cases which are ulti- 
mately fatal there is not such a speedy termination of the malady as is 
indicated in the above description. The choleriform diarrhoea abates 
and the case becomes one of ordinary summer complaint. 

Anatomical Characters. — Rilliet and Barthez, who of foreign 
writers treat of cholera infantum at greatest length, describe it under 
the name of gastro-intestinal choleriform catarrh. "The perusal," 
they remark, lt of anatomico-pathological descriptions, and especially 
the study of the facts, show that the gastro-intestinal tube in subjects 
who succumb to this disease may be in four different states : (a) either 
the stomach is softened without any lesion of the digestive tube; (b) or 
the stomach is softened at the same time that the mucous membrane of 
the intestine, and especially its follicular apparatus, is diseased ; (c) or 
the stomach is healthy, while the follicular apparatus or the mucous 
membrane is diseased ; (d) or, finally, the gastro-intestinal tube is not 
the seat of any lesion appreciable to our senses in the present state of 
our knowledge, or it presents lesions so insignificant that they are not 
sufficient to explain the gravity of the symptoms. 

"So far, the disease resembles all the catarrhs, but what is special 
is the abundance of serous secretion and the disturbance of the great 
sympathetic nerve. 

" The serous secretion, which appears to be produced by a perspira- 
tion ( analogous to that of the respiratory passages and of the skin ) 
rather than by a follicular secretion, shows, perhaps, that the elimina- 
tion of substances is effected by other organs than the follicles ; perhaps, 
also, we ought to see a proof that the materials to eliminate are not the 
same as in simple catarrh. Upon all these points we are constrained to 
remain in doubt. We content ourselves with pointing out the fact." 1 

On the 1st of August, 1861, I made the autopsy of an infant sixteen 
months old who died of cholera infantum with a sickness of less than 
one day. The examination was made thirty hours after death. Nothing 
unusual was observed in the brain, unless perhaps a little more than 
the ordinary injection of vessels at the vertex. No marked anatomical 
change was observed in the stomach and intestines, except enlargement 
of the patches of Peyer as w r ell as of the solitary and mesenteric glands. 
Mucous membrane pale. In this and the following cases there was 
apparently slight softening of the intestinal mucous membrane, but 
whether it was pathological or cadaveric was uncertain, as the weather 

1 Maladies des Enfants. 



ANATOMICAL CHARACTERS. 737 

was very warm. The liver seemed healthy. Examined by the micro- 
scope, it was found to contain about the normal number of oil-globules. 

The second case was that of an infant seven months old, wet-nursed, 
who died July 26, 1862, after a sickness also of about one day. He 
was previously emaciated, but without any marked ailment. The post- 
mortem examination was made on the 28th. The brain was somewhat 
softer than natural, but otherwise healthy. There was no abnormal 
vascularity of the membranes of the brain, and no serous effusion within 
the cranium. The mucous membrane of the intestines had nearly the 
normal color throughout, but it seemed somewhat thickened and soft- 
ened ; the solitary glands of the colon were prominent. The patches 
of Peyer were not distinct. 

In the New York Protestant Episcopal Orphan Asylum an infant 
twenty months old, previously healthy, was seized with cholera infantum 
on the 25th of June, 1864. The alvine evacuations, as is usual with 
this disease, were frequent and watery, and attended by obstinate vomit- 
ing. Death occurred in slight spasms in thirty-six hours. The excit- 
ing cause was probably the use of a few currants which were eaten in a 
cake the day before, some of which fruit was contained in the first evac- 
uations. The brain was not examined. The only pathological changes 
which were observed in the stomach and intestines were slightly vas- 
cular patches in the small intestines and an unusual prominence of the 
solitary glands in the colon. The glands resembled small beads im- 
bedded in the mucous membrane. The lungs in the above cases were 
healthy, excepting hypostatic congestion. 

Since the date of these autopsies I have made others in cases which 
terminated fatally after a brief duration, and have uniformly found sim- 
ilar lesions — to wit, the gastro-intestinal surface either without vascu- 
larity or scantily vascular in streaks or patches, sometimes presenting a 
whitish or soggy appearance and somewhat softened, while the solitary 
glands were enlarged so as to be prominent upon the surface. In cases 
which continue longer evident inflammatory lesions soon appear which 
are identical with those which have already been described in our 
remarks relating to the ordinary form of diarrhoea. 

During my term of service in the New York Foundling Asylum in 
the summer of 1884, an infant died after a brief illness with all the 
symptoms of cholera infantum, and the intestines were sent to William 
H. Welch, now of Johns Hopkins Hospital, for microscopic examina- 
tion. His report was as follows : "I found undoubted evidence of acute 
inflammation. There was an increased number of small, round cells 
(leucocytes) in the mucous and submucous coats. This accumulation 
of new cells was most abundant in and around the solitary follicles, which 
were greatly swollen. Clumps of lymphoid cells were found extending 
even a little into the muscular coat. The epithelial lining of the intes- 
tine was not demonstrable, but this is usually the case with post-mortem 
specimens of human intestine, and justifies no inferences as to patho- 
logical changes. The glands of Lieberkiihn were rich in the so-called 
goblet-cells, and some of the glands were distended with mucus and 
desquamated epithelium, so as to present sometimes the appearance of 
little cysts. This was observed especially in the neighborhood of the 



788 CHOLERA INFANTUM. 

solitary follicles. The bloodvessels, especially the veins of the sub- 
mucous coat, were abnormally distended with blood. I searched for 
microorganisms, and found them in abundance upon the free surface of 
the intestine, in the mucous accumulations there, and also in the mouths 
of the glands of Lieberkuhn. Both rod-shaped and small round bac- 
teria were found. I attach no especial importance to finding bacteria 
upon the surface of the intestine. The general result of the examina- 
tion is to confirm the view that cholera infantum is characterized by an 
acute intestinal inflammation." 

Nature. — Cholera infantum appears from its symptoms and lesions 
to be the most severe form of intestinal catarrh to which infants are 
liable. The alvine discharges, to which the rapid prostration is largely 
due, probably consist in part of intestinal secretions and in part of serum 
which has transuded from the capillaries of the intestines. That the 
intestinal mucous membrane sometimes presents a pale appearance at 
the autopsy of an infant who, previously well, has died of cholera in- 
fantum after a sickness of twenty-four or forty-eight hours, is perhaps 
due to the great amount of liquid secretion and transudation in which 
the inflamed surface is bathed. Moreover, it is, I believe, a recognized 
fact that the hyperemia of an acutely inflamed surface when of short 
duration frequently disappears in the cadaver, as that of scarlet fever 
and erysipelas. The early hyperplasia of the solitary and mesenteric 
glands, and the hypersemia and thickening of the surface of the ileum 
and colon in those who have survived a few day, indicate the inflamma- 
tory character of the malady. 

The opinion has been expressed by certain observers that cholera 
infantum is identical with thermic fever or sunstroke. There is indeed 
a resemblance to thermic fever as regards certain important symptoms. 
In cholera infantum the temperature is from 105° to 108° ; in sunstroke 
it is also very high, often running above 108°. Great heat of head, 
contracted pupils, thin fecal evacuations, embarrassed respiration, 
scanty urine, and cerebral symptoms are common toward the close of 
cholera infantum, and they are the prominent symptoms in sunstroke. 
Nevertheless, I cannot accept the theory which regards these maladies 
as identical, and which removes cholera infantum from the list of intes- 
tinal diseases. In cholera infantum the gastro-intestinal symptoms 
always take the precedence, and are, except in advanced cases, always 
more prominent than other symptoms. It does not commence as by a 
stroke like coup de soleil, but it comes on more gradually, though 
rapidly, and it often supervenes upon a diarrhoea or some error of diet. 
In the commencement of cholera infantum the infant is usually not 
drowsy, and is often wide awake and restless from the thirst. Contrast 
this with the alarming stupor of sunstroke. Sunstroke only occurs 
during the hours of excessive heat, but cholera infantum may occur at 
any hour or in any day during the hot weather, provided that there be 
sufficient dietetic cause. Again, intestinal inflammation is not common 
in sunstroke, while it is the common, or, as I believe, the essential 
lesion of cholera infantum. These facts show, in my opinion, that the 
two maladies are essentially and entirely distinct. Nevertheless, cases 
of apparent sunstroke sometimes occur in the infant, and if the bowels 



TREATMENT. 739 

are at the same time relaxed the disease may be regarded as cholera 
infantum, and if fatal is usually reported as such to the health authori- 
ties. Cases of this kind I have occasionally observed or they have been 
reported to me, although they are not common. 

With the exception of the organs of digestion no uniform lesions are 
observed in any of the viscera in cholera infantum, except such as are 
due to change in the quantity and fluidity of the blood and its circula- 
tion. Writers describe an anaemic appearance of the thoracic and 
abdominal viscera, and occasionally passive congestion of the cerebral 
vessels. The cerebral symptoms usually present toward the close of life 
in unfavorable cases of cholera infantum are often due to spurious 
hydrocephalus, which we have described above ; but as the urinary 
secretion is scanty or suppressed, cerebral symptoms may, in certain 
cases, be due to uraemia. 

Diagnosis. — This form of the summer diarrhoea is diagnosticated by 
the symptoms, and especially by the frequency and character of the 
stools. The stools have already been described as frequent, often passed 
with considerable force, deficient in fecal matter, and thin, so as to soak 
into the diaper almost like urine. The vomiting, thirst, rapid sinking, 
and emaciation serve to distinguish cholera infantum from other diar- 
rhoeal maladies. 

When Asiatic cholera is prevalent the differential diagnosis between 
the two is difficult if not impossible. 

Prognosis. — Cholera infantum is one of those diseases in regard to 
which physicians often injure their reputation by not giving sufficient 
notice of the danger, or even by expressing a favorable opinion when 
the case soon after ends fatally. A favorable prognosis should seldom 
be expressed without qualification. If the urgent symptoms be relieved, 
still the disease may continue as an ordinary intestinal inflammation, 
which in hot weather is formidable and often fatal. If the stools 
become more consistent and less frequent without the occurrence of 
cerebral symptoms, while the limbs are warm and the pulse good, we 
may confidently express the opinion that there is no present danger. 

The duration of true cholera infantum is short. It either ends 
fatally, or it begins soon to abate and ceases, or it continues, and is not 
to be distinguished in its subsequent course from an attack of summer 
diarrhoea beginning in the ordinary manner. 

Treatment of Infantile Diarrhcea. — Obviously, efficient preven- 
tive measures consist in the removal of infants so far as practicable from 
the operation of the causes which produce the disease. Weaning just 
before or in the hot weather should, if possible, be avoided, and removal 
to the country should be recommended, especially for those who are de- 
prived of breast-milk during the age when such nutriment is required. 
If for any reason it is necessary to employ artificial feeding for infants 
under the age of ten months, that food should obviously be used which 
most closely resembles human milk in digestibility and in nutritive 
properties. Care should be taken to prevent fermentation in the food 
before its use, since much harm is done by the employment of milk or 
other food in which fermentative changes have occurred and which 
occur quickly in dietetic mixtures in the hot months. 



740 CHOLERA INFANTUM. 

It is also very important that the infant receive its food in proper 
quantity and at proper intervals, for if the mother or nurse in her 
anxiety to have it thrive feed it too often or in too large quantity, the 
surplus food which it cannot digest if not vomited undergoes fermenta- 
tion, and consequently becomes irritating to the gastro-intestinal sur- 
face. The physician should be able to give advice not only in reference 
to the frequency of feeding, but also in regard to the quantity of food 
which the infant requires at each feeding. Correct knowledge and 
advice in this matter aid in the prevention and cure of the diarrhoeal 
maladies of infancy. The reader is referred to the chapters relating to 
the feeding of infants. Avoidance of exposure to cold or to sudden 
changes of temperature are important preventive measures, since cases 
of intestinal catarrh of infants occur from this cause, though less fre- 
quently than from errors in diet. 

Curative Treatment. — The indications for treatment are : 1st. To 
provide the best possible food, which will afford sufficient nutriment, 
and be easily digested. 2d. To aid the digestive functions of the infant. 
3d. To employ such medicinal agents as can be safely given to check 
the diarrhoea and cure the intestinal catarrh. 4th. To procure fresh 
air, which is especially needed if the diarrhoea be that of the summer 
season. 

The infant with this disease is thirsty, and is therefore likely to take 
more nutriment in the liquid form than it requires for its sustenance. 
If nursing, it craves the breast, or if weaned, craves the bottle, at short 
intervals, to relieve the thirst. No more nutriment should be allowed 
than is required for nutrition, for the reason stated above, and the thirst 
may best be relieved by a little cold water, gum-water, or barley-water, 
to which a few drops of brandy or whiskey are added. Infantile diar- 
rhoea of the summer season, so common and fatal in the cities, requires 
in some respects different treatment from that which is appropriate for 
diarrhoea occurring at other seasons, and due to other causes than those 
incident to hot weather. 

Since one of the two important factors in producing the summer 
diarrhoea is the use of improper food, it is obviously very important for 
the successful treatment of this disease that the food should be of the 
right kind, properly prepared, and given in proper quantity. I need 
not repeat that for infants under the age of one year no food is so suit- 
able as breast-milk, and one affected with the diarrhoea and remaining 
in the city should, if possible, at least if under the age of ten months, be 
provided with breast-milk. It can be more satisfactorily treated and 
the chances of its recovery are much greater if it be nourished with 
human milk than by any other kind of diet. If, however, the mother's 
milk fail or become unsuitable from ill-health or pregnancy, and on 
account of family circumstances a wet-nurse cannot be procured, the 
important and difficult duty devolves upon the physician of deciding 
how the infant should be fed. The reader is referred to Chapter VIII. 
Part L, for facts relating; to the feeding of infants. 

But since one of the two important factors in producing the summer 
diarrhoea of infants is foul air, it is obvious that measures should be 
employed to render the atmosphere in which the infant lives as free as 



CURATIVE TREATMENT. 741 

possible from noxious effluvia. Cleanliness of the person, of the bed- 
ding, and of the house in which the patient resides, the. prompt removal 
of all refuse animal or vegetable matter, whether within or around the 
premises, and allowing the infant to remain a considerable part of the 
day in shaded localities where the air is pure, as in the parks or suburbs 
of the city, are important measures. In New York great benefit has 
resulted from the floating hospital which, every second day during the 
heated term carries a thousand sick children from the stifling air of the 
tenement houses down the bay and out to the fresh air of the ocean. 

But it is difficult to obtain an atmosphere that is entirely pure in a 
large city with its many sources of insalubrity ; and all physicians of 
experience agree in the propriety of sending infants affected with the 
summer diarrhoea to localities in the country which are free from malaria 
and sparsely inhabited, in order that they may obtain the benefits of 
purer air. Many are the instances each summer in New York City of 
infants removed to the country with intestinal inflammation, with fea- 
tures haggard and shrunken, with limbs shrivelled and the skin lying in 
folds, too weak to raise, or at least hold, their heads from the pillow, 
vomiting nearly all the nutriment taken, with stools frequent and thin, 
resulting in great part from molecular disintegration of the tissues — 
presenting, indeed, an appearance seldom observed in any other disease 
except in the last stages of phthisis — and returning in late autumn with 
the cheerfulness, vigor, and rotundity of health. The localities usually 
preferred by the physicans of this city are the elevated portions of New 
Jersey and Northern Pennsylvania, the Highlands of the Hudson, the 
central and northern parts of New York State, and Northern New 
England. Taken to a salubrious locality and properly feci, the infant 
soon begins to improve if the disease be still recent, unless it be excep- 
tionally severe. If the disease have continued several weeks at the time 
of the removal, little benefit may be observed from the country residence 
until two or more weeks have elapsed. 

An infant weakened and wasted by the summer diarrhoea, removed to 
a cool locality in the country, should be warmly dressed and kept indoor 
when the heavy night dew is falling. Patients sometimes become worse 
from injudicious exposure of this kind, the intestinal catarrh from which 
they are suffering being aggravated by taking cold, and perhaps ren- 
dered dysenteric. 

Sometimes parents, not noticing the immediate improvement which 
they have been led to expect, return to the city without giving the 
country fair trial, and the life of the infant is then, as a rule, sacri- 
ficed. Returned to the foul air of the city while the weather is still 
warm, it sinks rapidly from an aggravation of the malady. Occasion- 
ally, the change from one rural locality to another, like the change from 
one wet-nurse to another, has a salutary effect. The infant, although 
it has recovered, should not be brought back while the weather is still 
warm. One attack of the disease does not diminish, but increases, the 
liability to a second seizure. 

Medicinal Treatment. The diarrhoea of infancy requires, to some 
extent, different treatment in its early and later stages. We have seen 
that acids, especially the lactic and butyric, the results of faulty 



742 INTESTINAL CATARRH OF INFANCY. 

digestion, are often produced, causing acid stools. In a few days the 
inflammatory irritation of the mucous follicles causes such an exag- 
gerated secretion of alkaline mucus that the acid is nearly or quite 
neutralized. In the commencement of the attack these acid and irri- 
tating products should be as quickly as possible neutralized, while 
we endeavor to prevent their production by improving the diet and 
assisting the digestion. In the second stage, when the fecal matter is 
less acid and irritating from the large admixture of mucus, medicines 
are required to improve digestion and check the diarrhoea, while the 
indication for antacids is less urgent. Therefore it is convenient to 
consider separately the treatment which is proper in the commencement 
or first stage, and that which is required in the subsequent course of the 
disease. 

First stage, or during the first three or four days, perhaps the first 
week. Occasionally, it is proper to commence the treatment by the 
employment of some gentle purgative, especially when the disease begins 
abruptly after the use of indigestible and irritating food. A single dose 
of castor oil or syrup of rhubarb, or the two mixed, will remove the 
irritating substance, and afterward opiates or the remedies designed to 
control the disease can be more successfully employed. Ordinarily, such 
preliminary treatment is not required. Diarrhoea has generally con- 
tinued several days when the physician is summoned, and no irritating 
substance remains save the acid which is so abundantly generated in 
the intestines in this disease, and which we have the means of removing 
without purgation. 

The same general plan of medicinal treatment is appropriate for the 
summer diarrhoea of infants as for diarrhoea from other causes ; but the 
acid fermentation present in greater degree in the former than in the 
latter, indicates the greater need of antacids, which should be employed 
in most of the mixtures used in the first stage as long as the stools have 
a decidedly acid reaction. 

Those who accept the theory that infantile diarrhoea of the summer 
season is produced by microorganisms which lodge on the gastro- 
intestinal surface and produce diarrhoea by their irritating effect, are 
naturally led to employ antiseptic remedies. Guaita administered for 
this purpose sodium benzoate. One drachm or a drachm and a half 
dissolved in three ounces of water were administered in twenty-four 
hours with, it is stated, good results. 1 I have no experience in the use 
of antiseptic remedies in any form of infantile diarrhoea. 

If by the appearance of the stools or the substance ejected from the 
stomach, or by the usual test of litmus-paper, the presence of an acid in 
an irritating quantity be ascertained or suspected, lime-water or sodium 
bicarbonate may be added to the food. The creta prseparata of the 
Pharmacopoeia administered every two hours, or, which is more con- 
venient, the mistura cretse, is a useful antacid for such a case. The 
chalk should be finely triturated. By alkalies alone, aided by the judi- 
cious use of stimulants, the disease is sometimes arrested, but, unless 
circumstances are favorable and the case be mild, other remedies are 
required. 

1 New York Medical Kecord, May 31, 1884. 



CURATIVE TREATMENT. 743 

Opium has long been used, and it retains its place as one of the im- 
portant remedies in infantile diarrhoea. For the treatment of a young 
infant paregoric is a convenient opiate preparation. For the age of 
one or two months the dose is from three to five drops ; for the age of 
six months, twelve drops, repeated every three hours or at longer in- 
tervals according to the state of the patient. After the age of six 
months the stronger preparations of opium are more commonly used. 
The tinctura opii deodorata or Squibb's liquor opii compositus may be 
given in doses of one drop at the age of one year. Dover's powder in 
doses of three-fourths of a grain, or the pulvis cretse comp. cum opio in 
three-grain doses every third hour, may be given to an infant of one year. 

Opium is, however, in general best given in mixtures which will be 
mentioned hereafter. It quiets the action of the intestines and dimin- 
ishes the number of the evacuations. It is contraindicated or should be 
used with caution if cerebral symptoms are present. Sometimes in the 
commencement of the disease, when it begins abruptly from some error 
in diet, with high temperature, drowsiness, twitching of the limbs — 
symptoms which threaten eclampsia — opiates should be given cautiously 
before free evacuations occur from the bowels and the offending sub- 
stance is expelled. Under such circumstances a few doses of the bromide 
of potassium are preferable. In the advanced stage of the disease also, 
when symptoms of spurious hydrocephalus occur, opium should be with- 
held or cautiously administered, since it may tend to increase the fatal 
stupor in which severe cases are liable to terminate ; but, except in such 
cases, opium is a most useful remedy. 

The vegetable astringents, although they have been largely employed 
in the treatment of the various forms of infantile diarrhoea, are much 
less frequently prescribed than formerly. As a substitute for them the 
subnitrate of bismuth has come into use, and in much larger doses than 
were formerly employed. While it aids in checking the diarrhoea, it is 
an efficient antiemetic and antiseptic. It should be prescribed in ten or 
twelve grains for an infant of twelve months ; larger doses produce no 
ill effect, for its action is almost entirely local and soothing to the in- 
flamed surface with which it comes in contact. It undergoes a chemical 
change in the stomach and intestines, becoming black, being converted 
into the bismuth sulphide, and it causes dark stools. Rarely it pro- 
duces in the infant the well-known garlicky odor, like that occasionally 
observed in adult patients, and which is supposed to be due to tellurium 
accidentally associated with the bismuth in its natural state. For those 
cases in which the symptoms are chiefly due to colitis, and the stools 
contain blood with a large proportion of mucus, it has been customary 
to prescribe laudanum or some other form of opium with castor oil. I 
prefer, however, the bismuth and opium for such cases as are more de- 
cidedly dysenteric, as well as for cases of the usual form of intestinal 
catarrh. 

The following are convenient and useful formulae for a child of one year: 

R. — Tinct. opii deodorat Ttt xv j- 

Bismuth, subnitrat. . . . - . • 5'j- 

Syrupi 1 3 ij 

Misturse cretae ....... f 3 xiv. — Misce. 

Shake thoroughly and give one teaspoonful every two to four hours. 



744 INTESTINAL CATARRH OF INFANCY. 

R. — Tinct. opii deodorat Tfl xvj. 

Bismuth, subnitrat zy. 

Syrupi i ?ss 

Aq. cinnamomi f"Siss. — Misce. 

Shake bottle ; give one teaspoonful every two to four hours. 

R. — Bismuth, subnitrat ^ij 

Pulv. cret. comp. c. opio gss. — Misce. 

Divid in chart No. x. Dose, one powder every three hours. 

R. — Bismuth, subnitrat . . . ^ij. 

Pulv. ipecac, comp gr. ix. — Misce. 

Divid in chart No. xii. Dose, one powder every three hours. 

Cholera infantum requires similar treatment to that which is proper 
for the ordinary form of infantile diarrhoea, but there is no disease, 
unless it is pseudo-membranous croup, in which early and appropriate 
treatment is more urgently required, since the tendency is to rapid sink- 
ing and death. As early as possible, therefore, proper instructions 
should be given in regard to the feeding, and for an infant between the 
ages of eight and twelve months either one of the above prescriptions 
should be given or the following : 



R . — Tinct. opii deodorat. . 
Spts. ammon. aromat. 
Bismuth, subnitrat. . 
Mucil. acacise vel syrupi 
Misturse cretae 



f ±ss. 

f liss — Misce. 



Shake bottle. Give one teaspoonful every two or three hours. 

An infant of six months can take one-half the dose, and one of three 
or four months one-third or one-fourth the dose, of either of the above 
mixtures. 

If cerebral symptoms appear, as rolling the head, drowsiness, etc., I 
usually write the prescription without the opiate ; and with this omission 
it may be given more frequently if the case require it, while the opiate 
prescribed alone or with bromide of potassium is given guardedly and at 
longer intervals. Injury to the patient from the use of the opiate can 
only occur through carelessness in not giving proper attention to his 
condition. It is chiefly in advanced cases, when the vital powers are 
beginning to fail, when the innervation is deficient, and cerebral circula- 
tion sluggish, that the use of opiates may involve danger. Explicit and 
positive directions should be given to omit the opiate or to give it less 
frequently whenever the evacuations are checked wholly or partially and 
signs of stupor appear. 

Second Stage. Infantile diarrhoea in a large proportion of cases 
begins in such a gradual wav that the treatment which we are about to 
recommend is proper in many instances at the first visit of the physi- 
cian, who is frequently not summoned until the attack has continued 
one or two weeks. The alkaline treatment recommended above for the 
diarrhoea in its commencement does not aid digestion sufficiently to 
justify its continuance as the main remedy after the first few days. In 
a large number of instances, however, one of the above alkaline mix- 
tures may be given with advantage midway between the nursings or 



CURATIVE TREATMENT. 745 

feedings, while those remedies, presently to be mentioned, which facili- 
tate digestion and assimilation are given at the time of the reception 
of food. 

Some physicians of large experience, as Henoch, of Berlin, recom- 
mend small doses of calomel, as the twelfth or twentieth of a grain, 
three or four times daily for infants with faulty digestion and diarrhoea. 
To me, this seems an uncertain remedy, without sufficient indications 
for its use, and I have therefore no experience with it. The following 
are formulae which I employ in my own practice, which have been em- 
ployed with apparent good results in the institutions in New York in 
those frequent cases in which diarrhoea is associated with indigestion : 

R. — Acid, muriat. dilut TTl ST J- 

Pepsinaa saccharat. (Havdey's or other good pepsin) gj. 

Bismuth, subnitrat 3pj. 

Syrupi ; f^ij. 

Aquae ......... f^xiv. — Misce. 

Shake bottle ; give one teaspoonful before each feeding or nursing to an infant 
of one year ; half a teaspoonful to one of six months. 



R. — Tinct. opii deodorat. 
Pepin 83 saecharat. 
Bismuth, subnitrat. 
Syrupi . 
Aquae 



f £ xiv. — Misce. 



Shake bottle : give one teaspoonful every three hours to a child of one year j 
half a teaspoonful to one of six months. 

R. — Pepsinaa saccharat gj— ij. 

Bismuth, subnitrat. gij. — Misce. 

Divid in chart No. xii. One powder every three hours to a child of one year. 

In occasional case? in which the stomach is very irritable, so that 
medicines given by the mouth are in great part rejected, our reliance 
must be largely on rectal medication, and especially on clysters contain- 
ing an opiate. Laudanum may be given in this manner with marked 
benefit. It may be given mixed with a little starch-water, and the best 
instrument for administering it is a small glass or gutta-percha syringe, 
the nurse retaining the enema for a time by means of a compress. 
Beck, in his Infant Therapeutics, advises to give by the clyster twice as 
much of the opiate as would be required by the mouth. A somewhat 
larger proportion may, however, be safely employed. The following 
formula for a clyster has given me more satisfaction than any other 
medicated enema which I have employed : 

R. — Argent, nitrat gr. iv. 

Bismuth, subnitrat ^ss. 

Mucilag. acaciae) __-,-,.. ^ r . 

Aquae } aa f gij.— Misce. 

One-quarter to one-half of this should be given at a time, with the 
addition of as much laudanum as is thought proper ; and it should be 
retained by the compress. It is especially useful when from the large 
amount of mucus or mucus tinged with blood it is probable that the 
descending colon is chiefly involved. 



740 INTESTINAL CATARRH OF INFANCY. 

Alcoholic stimulants are required almost from the commencement of 
the disease, and they should be employed in all protracted cases. 
Whiskey or brandy is the best of these stimulants, and it should be 
given in small doses at intervals of two hours. I usually order three or 
four drops for an infant of one month, and an additional drop or two 
drops for each additional month. The stimulant is not only useful in 
sustaining the vital powers, but it also aids in relieving the irritability 
of the stomach and in preventing hypostasis in depending portions of the 
lung and brain, which, as we have seen, is so frequent in advanced cases. 

The vomiting which is so common a symptom in many cases greatly 
increases the prostration, and should be immediately relieved if possible. 
The following formulae will be found useful for it : 

R. — Bismuth, subnitrat. . . . . . gij. 

Spts. aramon. aroinat i'gss-^j. 

%2'} aafgj.-Misce. 

Shake bottle. Dose, one teaspoonful half-hourly or hourly if required, made cold 
by a piece of ice. 

R. — Acid, carbolic . gtt. ij. 

Liquor, calcis ....... f^ij — Misce. 

Dose, one teaspoonful, with a teaspoonful of milk (breast-milk if the baby nurse), 
to be repeated according to the nausea. 

Lime-water with an equal quantity of milk often relieves the nausea 
when it is due to acids in the stomach, but it is rendered more effectual 
in certain cases by the addition of carbolic acid, which tends to check 
any fermentative process. A minute dose of tincture of ipecacuanha, 
as one-eighth of a drop in a teaspoonful of ice-water, frequently repeated, 
has also been employed with alleged benefit. 

Of these various antiemetics, my preference is for the bismuth in large 
doses, with the aromatic spirits of ammonia, properly diluted, that the 
ammonia do not irritate the stomach. Nevertheless, in certain patients 
the nausea is very obstinate, and all these remedies fail. In such cases 
absolute quiet of the infant on its back, the administration of but little 
nutriment at a time, mustard over the epigastrium, and the use of an 
occasional small piece of ice or the use of carbonic acid water with ice 
in it, may relieve this symptom. 

In protracted cases, when the vital powers begin % to fail, as indicated 
by pallor, more or less emaciation, and loss of strength, the following is 
the best tonic mixture with which I am acquainted. It aids in restrain- 
ing the diarrhoea, while it increases the appetite and strength. It should 
not be prescribed until the inflammation has assumed a subacute or 
chronic character: 

R — Tinct. columbse f 3^ i i j . 

Liq. ferri nitratis tt|xxvij. 

Syrupi f^ n j- — Misce. 

Dose, one teaspoonful every three or four hours to an infant of one year. 

External Treatment. — Some writers recommend depletion by 
leeching in intestinal inflammation, when the infant is robust and of 
full habit, and the disease commences suddenly with decided febrile 



ENTERITIS AXD COLITIS IN CHILDHOOD. 747 

reaction. Such cases are oftenest seen with us in the winter season, 
and even these are ordinarily best treated without loss of blood. Sina- 
pisms and poultices usually are sufficient as local measures. In these 
cases, also, the warm mustard foot-bath should be employed, and repeated 
if there be restlessness or cerebral symptoms. 

In all forms of intestinal inflammation in infancy and in all its stages 
mild counter-irritation over the abdomen is often useful, but vesication, 
by increasing the restlessness of the infant and reducing its strength, 
without materially modifying the severity or duration of the disease, 
does more harm than good. It is not to be thought of as a remedial 
measure. I have known a troublesome sore continuing till death, and 
probably hastening this result, to occur from this treatment. Poultices 
or fomentations over the abdomen are sometimes beneficial, especially 
those of a mildly irritating nature. A poultice of powdered cloves, cin- 
namon, and ginger, or of linseed meal to which a little mustard is added, 
may be employed, or a linseed poultice spread thin, under which a single 
layer of muslin is placed, saturated with camphorated oil or tincture of 
camphor, and over both oil silk. In the entero-colitis of infants, occur- 
ring in the cool months, and due to exposure to cold, this treatment is 
especially useful. In the epidemic entero-colitis of the summer months, 
which may be aggravated by heat, treatment by poultices may be inju- 
dicious, but in such cases it is proper to produce moderate redness over 
the abdomen by temporary applications. 



CHAPTEE IX. 

EXTEKITIS AXD COLITIS IX CHILDHOOD. 

Intestinal inflammation in childhood differs materially from the 
form or type which it commonly presents in infancy. Its causes, symp- 
toms, and extent vary in important particulars in the two periods. In 
childhood there is not ordinarily such extensive inflammation of the 
mucous membrane of the intestines as we have seen is present in the 
majority of cases in infancy, and it may, therefore, be properly treated 
as two diseases, according to the seat of the morbid process, namely, 
enteritis and colitis. Both these affections in the child resemble so 
closely the form which they exhibit in adult life, that no extended 
description is needed in this connection. 

Causes. — A main cause is sudden reductions of temperature by 
exposure to cold, or to currents of air, which checks perspiration, and 
causes determination of blood from the surface to the viscera. These 
inflammations are also caused sometimes "by irritating substances in the 
intestines. I have known fecal accumulations as well as worms to 
produce severe dysentery in the child, accompanied by the characteristic 



748 ENTERITIS AND COLITIS IN CHILDHOOD. 

tenesmus and muco-sanguineous stools, and ceasing as soon as the offend- 
ing substances were expelled. The use of unripe or stale vegetables, if 
there be a strong predisposition to mucous inflammation, may be a suf- 
ficient cause, and some of the most dangerous cases are due to the accu- 
mulation in the intestines of seeds and the parenchyma of fruits. But 
the most common cause is that mentioned, namely, sudden exposure to 
cold when the body is heated, a danger to which children are especially 
liable, on account of the easy disturbance of the circulatory system in 
them, and their heedless exposure of themselves, unless incessantly 
watched. Enteritis and colitis are also frequently secondary diseases 
occurring in childhood as complications or sequelae of the eruptive 
fevers, especially measles. 

Symptoms. — The alvine discharges in enteritis and colitis in child- 
hood are such as occur in these diseases at a more advanced age. In 
enteritis they are thin and of the natural color, or occasionally green \ 
in colitis they are more consistent than in enteritis, and are largely 
muco-sanguineous. Sometimes in enteritis, if the inflammation be not 
intense, the diarrhoea is slow in appearing, or it may be slight, so as 
not to attract special attention. The disease may then resemble remit- 
tent fever, for which it is at times mistaken. The upper part of the 
small intestines is less frequently affected than the lower. If there be 
duodenitis, the flow of bile is occasionally impeded from tumefaction of 
the mouth of the common bile-duct, and the icteric hue appears. In 
both enteritis and colitis there is abdominal tenderness, with more or 
less constant pain if the disease be severe, and in colitis, tormina and 
tenesmus. The pulse is accelerated, the heat of surface augmented, the 
face flushed, and, except in mild cases, expressive of pain. In many 
children at the commencement of the inflammation the nervous system 
is profoundly affected, as indicated by headache, stupor, twitching of 
the limbs, and sometimes by convulsions. The chief danger at the com- 
mencement of the disease is, indeed, from this source. Sometimes irri- 
tability of the stomach occurs, and the food is rejected, though much 
less frequently than in the intestinal inflammation of infancy. Anorexia 
and thirst are common symptoms. If the inflammation continue, there 
is soon perceptible emaciation, with loss of strength. The eyes become 
hollow, the face pallid, and the surface cool. Death may occur at an 
early period, the vital powers succumbing from the intensity of the in- 
flammation. In other cases, the acute disease ends in a subacute or 
chronic inflammation ; the patient becomes gradually more reduced, till 
he dies in a state of extreme emaciation, such as we often observe in the 
entero-colitis of infancy ; or from this state he may recover by degrees, 
though perhaps with an irritable state of the bowels, which continues 
for months. In a majority of cases, however, enteritis and colitis in 
childhood, if properly treated, soon begin to yield, and they terminate 
favorably in one or two weeks. 

Diagnosis. — It is not difficult to determine the existence of the in- 
flammation. This is indicated by the fever, abdominal tenderness, and 
the relaxed state of the bowels. Whether the disease be enteritis or 
colitis is determined by the character of the stools, the seat of the tender- 
ness and the presence or absence of tenesmus. 



TREATMENT. 749 

Prognosis. — It has been stated above that enteritis and colitis in 
children commonly terminate favorably. The result depends not only 
on the extent and severity of the inflammation, but the constitution and 
previous health. The inflammation is more serious when secondary 
than when primary. Extensive and great tenderness of the abdomen, 
features pallid, anxious, and expressive of suffering, pulse frequent and 
feeble, should excite the most serious apprehensions. Frequent vomit- 
ing also denotes a grave form of the disease. Stupor, and especially 
convulsive movements, show that the nervous centres are affected, and 
should make us guarded in the prognosis. Improvement in the dis- 
ease, on which to base a favorable prediction, is apparent in the diminu- 
tion of the tenderness, improvement in the pulse and character of the 
stools, a more cheerful countenance, and less disrelish of food. 

Treatment. — This should be similar to that employed for the adult. 
In enteritis at the commencement of the disease, if there be reason to 
suspect the presence of any irritating substance in the intestines, and 
ordinarily in colitis, it is advisable to commence treatment by the use 
of some simple evacuant, like castor oil. After this our reliance, so far as 
internal treatment is concerned, must be mainly on opiate and antiphlo- 
gistic medicines. One of the best remedies of this class is the Dover's 
powder, which may be given to a child five years old in doses of three 
grains every three hours. A corresponding dose of any of the other 
opiates may be given, but with less sudorific effect. In colitis the occa- 
sional administration of a laxative should not be neglected, if the stools 
be entirely or mainly muco-sanguineous. It should be employed so as 
to prevent accumulation of fecal matters in the colon, which would serve 
as an irritant and increase the inflammation. The dose should be small, 
merely sufficient to produce fecal evacuation, and repeated as required, 
daily or less frequently. The laxatives commonly preferred are mag- 
nesia, rhubarb, or castor oil. The physician may prescribe an opiate 
mixture containing sufficient of the laxative to have the effect desired, 
though ordinarily it is better to prescribe the two separately, so that 
the laxative can be given or withheld, according to circumstances, while 
the opiate is continued more regularly. Except that there be some 
irritating substance which requires removal, the effect of laxatives is in- 
jurious, instead of beneficial. Most of the formulae given above in our 
remarks relating to the treatment of infantile intestinal catarrh are like- 
wise useful for the enteritis and colitis of childhood, the quantity of the 
opiate, which is the important ingredient, being increased according to 
the increase in the age. The following prescriptions may be employed 
for a child of five years : 

R. — Pulv. opii gr. v. 

Bismuth, subnitrat. ...... gij. — Misce. 

Divid in pulveres ~No. xx. Give one powder every two to four hours. 

R. — Pulv. ipecac, comp. . . . . . gj. 

Bismuth, subnitrat. ...... gij. — Misce. 

Divid in pulveres No. xxiv. Give one powder as above. 

R. — Tine, opii deodorat. . . .- ■ - . . gss. 

Bismuth, subnitrat. . . . . . ^ij. 

Aq. menth. piperit., 

Syr. zingiberis aa ^j. — Misce. 

Shake bottle. Give one teaspoonful from two to four hours. 



750 CONSTIPATION. 

The local treatment which is found most useful consists in the use of 
emollient applications covered with oil-silk, and made sufficiently irritat- 
ing by mustard or otherwise to cause constant redness. 

The diet should be bland and unirritating. In the first stages of the 
inflammation, rice or barley-water, or arrowroot boiled in water, and 
similar drinks should constitute the main diet. When the active in- 
flammation has abated, and at any period of the disease if there be a 
tendency to prostration, more nourishing food should be given. Milk 
and animal broths may then be allowed. In cases which are protracted, 
or attended with symptoms of exhaustion, alcoholic stimulants are re- 
quired. 



CHAPTEE X. 

CONSTIPATION 

The gastro-intestinal portion of the digestive apparatus has a double 
function. First, it receives and retains the food during the process of 
digestion ; it furnishes the most important of the liquids by which diges- 
tion is effected, and it absorbs those products of digestion which are re- 
quired for the nutrition of the body, while it serves as a barrier against 
the admission of refuse matter. Secondly, it has an excretory function, 
so that a large part of the waste and noxious products of the system are 
eliminated from its surface. Having, therefore, a relation so close and 
fundamental to the general nutrition, it is necessary,- for the normal 
activity of the organs and the maintenance of health, that its functions 
be regularly and fully performed. But retention of fecal matter beyond 
the normal period is one of the most common ailments both in infancy 
and childhood, and occasionally it constitutes a grave disease. 

Constipation is of two kinds, namely, symptomatic and idiopathic. 

Symptomatic Constipation. Causes. — Many of these are ob- 
structive. The more common of them are the following : (a) Congenital 
stenosis, or occlusion of the anus or rectum. The anus is not formed, 
or it terminates in a cul-de-sac, while the lower end of the large intes- 
tines forms another cul-de-sac. These two cul-de-sacs, lying opposite 
each other, one looking upward and the other downward, may be sepa- 
rated from each other by a small interspace, a fibrous septum, so that 
relief can be obtained by a puncture or incision, or they may be widely 
separated, so that there is no possible mode of relief, and death is in- 
evitable, unless the fecal matter escape through a congenital fistulous 
passage upon one of the adjacent mucous surfaces, which mode of relief 
was present in forty per cent, of the cases of this obstruction collected 
by Leichtenstern. Exceptionally this malformation occurs in the sig- 
moid flexure, while the rectum is normal. The stenosis, if slight, may 



SYMPTOMATIC CONSTIPATION — CAUSES. 751 

produce little delay in the evacuations, except when hardened masses or 
coase, indigestible substances descend upon it, and it may, therefore, 
with careful selection of diet, cause little inconvenience for a lengthened 
period, while much stenosis causes early obstructive symptoms. 

Rarely the stenosis is at the ileo-caecal orifice. Thus, in the Trans- 
actions of the Lond. Path. Soc, for 1870, is the history of a case in 
which there was such narrowing of the ileo-caecal orifice, believed to be 
congenital, that a No. 9 catheter could barely be passed through it. 
The patient lived till his thirty-second year, having suffered from an 
early age with frequent attacks of colic and constipation. After his 
death, the ileum next to the ileo-caecal valve was found to have a diam- 
eter of seven inches, while the large intestine was much atrophied, and 
its entire lumen contracted from the long disuse. Occasionally, the 
narrowing occurs a little above the ileo-caecal orifice, and more rarely in 
the duodenum, at the point of union of the pancreatic or bile-duct with 
the intestine. In the last situation, the obstacle sometimes appears to be 
hypertrophied valvulse conniventes, the edges of two opposite folds be- 
coming more or less adherent. Such congenital intestinal obstructions, 
whether, as is probable, produced by inflammations in the foetus or from 
simple perverted nutrition; whether arising from syphilitic cachexia or 
other cause, of course retard the evacuations, according to their loca- 
tions and the degree of closure. The same degree of stenosis in the 
colon or rectum obviously causes more constipating effect than in the 
small intestine, since the excrementitious substance is firmer in the 
former than in the latter, and the latter have more mobility by which to 
overcome obstacles. 

(6) Intestinal Displacements. — These produce obstructions of a very 
painful and dangerous kind. Intussusception and external hernia are 
too well known to require description. Both are likely to produce com- 
plete obstruction if not soon relieved, but there are cases of intussuscep- 
tion in children in which the displaced intestine remains pervious, and 
the evacuations occur with more or less regularity ; and the same is true 
of one form of hernia, namely, the congenital, which, although painful, 
seldom produces serious obstruction. 

Painful and dangerous occlusion and consequent arrest of alvine evac- 
uations occasionally result from the imprisonment of a loop of intes- 
tine in an opening, usually congenital, in the mesentery or diaphragm, 
or from the knotting of one portion of intestine with another, as de- 
scribed by Leichtenstern, or again from the twisting of the intestine. 
Epstein and Soyka 1 relate the case of a newborn infant that died in the 
second week after birth with symptoms of obstruction. At the autopsy, 
a portion of the small intestine with its mesentery was found twisted 
upon its axis, from right to left, without any marked evidence of inflam- 
mation. 

(<?) Substances which have been swallowed, or substances whose nuclei 
have been swallowed, and which consist of a deposit of carbonate and 
phosphate of lime, or substances which have been produced entirely in 
the system, and which, lodged in narrow parts of the intestine, cause 

1 Centralb. f. d. med. Wissensch., April 24, 1879. 



752 CONSTIPATION. 

obstruction. Such substances, some of which occur most frequently 
in children, and others in elderly people, produce acute constipation. 
Indigestible matter contained in the food, as seeds or the parenchyma- 
tous portions of fruits, occasionally collects in considerable quantity and 
obstructs the intestine. A large gall-stone, having escaped from the 
common bile-duct, sometimes lodges in the intestine, either at the ileo- 
cecal valve or, more rarely, at some other point, and retards the pass- 
age of fecal matter. But this seldom occurs in children. 

In one instance, and in only one, have I known obstinate constipa- 
tion to be produced by worms. The patient was a girl of about four 
years, in whom constipation came on suddenly, and was accompanied by 
distention of abdomen and great suffering. This continued nearly one 
week, when a mass of intertwined round worms was expelled, with im- 
mediate relief. The records of medicine also contain cases in which 
neoplasms, growing from the coats of the intestines internally, have at- 
tained such a size as to retard the evacuations. 

(d) Abscesses and tumors, especially when occurring in the pelvis, 
also sometimes cause constipation by pressing upon the intestine, and 
obstructing or narrowing the passage through it. Thus, in 1868, Mr. 
Thomas Smith related to the London Pathological Society the case of an 
infant, aged fourteen months, in whom both alvine and urinary evacua- 
tions were retarded by a cancerous tumor growing between the rectum 
and bladder, and ending fatally in three months after the occurrence of 
the first symptoms. 

(e) Peritonitis, during its continuance, is known to constipate the 
bowels. It is supposed that inflammatory oedema occurs around the 
muscular fibres of the middle coat, by which their contractility is im- 
paired. Hence the lax state, the meteorism, and inaction of the intes- 
tines in this disease. When the peritonitis abates, the normal action is 
restored, and the evacuations occur regularly, if the free surface of the 
peritoneum have undergone no unfavorable change. But unfortunately 
peritonitis often produces more lasting injury, so as to interfere seriously 
with the intestinal movements, and produce an habitually torpid state 
of the bowels. This occurs from adventitious bands of inflammatory 
origin, which lie across the intestines, compressing them at the points 
of contact, and restraining their movements, and from adhesion of the 
intestinal loops. 

The most marked cases which I have observed of this were children 
who had had tubercular peritonitis. The following was an interesting 
example : 

Case. — Charles, aged 4 years, was returned to the New York Found- 
ling Asylum on April 16, 1877, to be treated for tumor albus of the left 
knee, and for general ill-health. His parentage and early history were 
unknown. The nurse in the city, to whom he had been entrusted when 
quite small, stated that he had no sickness when with her, except sore 
eyes, and that about April 1, 1877, the enlargement of the knee was first 
observed. The head of the boy was large, and the abdomen much dis- 
tended, but without any decided tenderness on pressure ; its entire lower 
part had a purplish color. Percussion over it gave a dull sound, except 
upon and near the epigastrium, where there was some resonance ; umbili- 



SYMPTOMS. 753 

cus prominent ; circumference of body over abdomen, 23 inches ; pulse 
128 ; axillary temperature 99°. It was stated that he had no stool with- 
out medicine, and that, usually, one tablespoonful of castor oil was 
required to produce it. The urine contained no albumen, and was 
apparently normal. As the appearance indicated struma, a mixture of 
cod-liver oil, syrup of the lacto-phosphate of lime, and iron was pre- 
scribed, to be given three times daily, and directions were given to rub 
cod-liver oil over the abdomen also three times each day, for five minutes 
each time. Some nodules were felt, on pressure upon the abdomen, which 
we suspected were enlarged mesenteric glands. From the day on which 
the friction and kneading of the abdomen were commenced, the stools 
began to occur, on the average, about twice daily. The kneading proved 
the safest, as well as most efficient, method of producing defecation. 

On May 4th, the circumference of the trunk over the most prominent 
part of the abdomen was reduced to twenty-two inches. The records on 
May 11th state : "Same treatment is continued; has tolerable appetite, 
but is pallid, and his flesh flabby and soft." On May 22d, the circum- 
ference of the trunk gave 22f inches. The tumor albus remained about 
the same. 

I saw the patient again during attendance in the asylum, in August and 
November. The record in November states that he is feeble and failing ; 
is becoming weaker and thinner ; breath and exhalations from the sur- 
face offensive ; he is kept quiet on account of the knee. From this time 
he gradually failed, and died April 11, 1878. There was no cough to 
attract attention; and instead of constipation, a diarrhoea of some weeks' 
continuance preceded death. 

Autopsy. — Lungs healthy, except a little exudation over the summit 
of right lung ; bronchial glands cheesy ; numerous tubercles, some of them 
cheesy, upon the parietal and visceral surface of the peritoneum. Loops 
of the intestines were united to each other by old adhesions, and the small 
intestines were generally bound doAvn by bands into a " uniform con- 
glomeration ;" mesenteric glands enlarged and cheesy ; a large ulcer upon 
the surface of the rectum, and numerous small, round ulcers upon the 
surface of small and large intestines, apparently occupying the site of the 
solitary follicles. 

Occasionally, a false band, the result of peritonitis, lies across the 
intestines, without restraining their movements, and producing no 
marked symptoms, and probably no symptoms at all, until a loop 
happens to pass underneath it, when, if not soon released, it is liable to 
become strangulated, with complete obstruction to the passage of fecal 
matter. This displacement might properly be classified with the inter- 
nal hernias described above. In my own person, at the age of twelve 
years, such an accident occurred about two months after the peritonitis. 
L T pon the abatement of the inflammation, a sensation of traction had 
been noticed in the umbilical region, almost daily, during exercise, and 
the displacement was indicated by the extreme pain which characterizes 
such cases, and which ceased suddenly, when the parts were released 
after about eighteen hours. 

(/) While it is important that the diet and glandular secretions 
should be such that the feculent matter may have proper consistence, 
for easy propulsion along the intestinal tube, the important agent by 
w T hich alvine evacuations are effected is obviously muscular contraction. 

48 



754 CONSTIPATION. 

The muscular fibres of the intestines produce the vermicular and peri- 
staltic movements by which the excrement is carried forward, and the 
abdominal muscles, by their powerful contraction, are the chief agents 
of expulsion. Now any pathological state which impairs the innerva- 
tion of these muscles, or renders it abnormal, destroying the proper 
balance between " exciting and inhibiting impulses," is likely to cause 
constipation. Hence meningitis, myelitis, and certain other diseases 
of the cerebro-spinal axis, rachitis, general weakness, etc., are com- 
monly attended by a sluggish state of the intestines, either from tonic 
contraction of the muscular fibres of the middle coat, as in meningitis, 
or paralysis. 

Idiopathic Constipation. Causes. — These are quite numerous. 
The more prominent of them are the following. First, too little liquid 
in the excrement, so that it is too firm for ready evacuation. There 
may be too little liquid taken in the ingesta, or too scanty secretion of 
the liquids which mix with the food, as those of the pancreas, liver, and 
mucous follicles, or there may be too great an absorption of liquid 
through the coats of the intestines, and too active an excretion of water 
from the skin, kidneys, or lung. The firmer the fecal matter, the 
greater the tendency to constipation. Those who lose a large amount 
of water, as in diabetes, night sweats, or from occupations which expose 
to heat, or from residence in a hot climate, are especially liable to con- 
stipation, except as the loss of liquid is compensated by an increased 
amount of drink. 

The character of the food, apart from the amount of liquid which it 
contains, obviously has a marked influence upon the consistence and fre- 
quency of the stools. Occasionally, the intestines act sluggishly from 
insufficiency of food. Thus, the infant sometimes hangs an unusually 
long time on the breast, and the mother or wet-nurse believes it to be a 
hearty nurser, when there is really a deficiency of milk, and the stools 
are scanty and infrequent from lack of material. Again, constipation 
is not uncommon in infants who nurse heartily, and seem to obtain a 
sufficient quantity of milk, and the cause of it is not in the state of the 
digestive organs, but in the milk. We find that now and then breast- 
milk has a constipating effect, although we discover nothing to cause 
this result in the mother's diet or health. The comparison of ordinary 
milk with colostrum may furnish a clew to the explanation. Colostrum 
is known to be more laxative than ordinary milk, and it differs from it 
chemically in containing more butter, sugar, and salts. Hence the 
theory seems plausible that, when breast-milk is constipating, these 
elements occur in less than the normal quantity. And we shall see here- 
after that treatment suggested by this theory obviates the constipation. 

The use of a diet which consists chiefly of assimilable substances, as 
animal food, and from which, after the digestive process, little coarse and 
stimulating residuum remains, is obviously liable to produce a sluggish 
state of the bowels. On the other hand, coarse food, as fruits with their 
seeds, coarsely ground meal, etc., which stimulates the peristaltic action 
and the secretions, increases the number and frequency of the alvine 
discharges. 

Habit also exerts a decided influence upon defecation. One who, for 



SYMPTOMS. 755 

whatever reason, neglects or resists the desire for a stool, soon becomes 
less conscious of the daily recurring need, and establishes a constipated 
habit. Constipation is more liable to occur in those who lead a quiet 
life than in those who are active. A constipated habit is established in 
many school children, by neglecting or repressing the desire for a stool, 
during school hours. 

But there are cases in which there seems to be a constitutional ten- 
dency to constipation — a tendency quite independent of the usual condi- 
tions. Thus I have met children who were bright and active, free from 
obstruction or disease which might retard the evacuations, apparently 
far from having sluggish muscular contractility, and so far as I could 
see with proper diet, and yet with defecation, except as it was produced 
by measures employed, occurring no oftener than each second, third, or 
fourth day. 

But it must be borne in mind that what is constipation in one child 
may not be in another, for occasionally one does well with only one 
evacuation every second or third day, while a large majority require 
daily defecation, in order to the maintenance of perfect health. 

In the adult, the sacculi or pouches which occur in the walls of the 
colon, produced by contraction of the longitudinal bands, acting at right 
angles to the direction of the circular fibres, and consisting of the inter- 
nal and external tunics, without the muscular, become the receptacles 
for fecal matter in those who are constipated, and obviously tend to in- 
crease the constipation. In children these sacculi are much less devel- 
oped relatively, and in young infants whose intestines lack the longi- 
tudinal bands, are absent, so that this anatomical condition by which 
the passage of fecal matter is delayed, is unimportant as a cause of con- 
stipation in the young. 

Grautier, of Geneva, Switzerland, states that an anal fissure is a com- 
mon cause of constipation in children. Pain in defecation when such a 
fissure is present might induce children to resist the desire, and postpone 
the act, and thereby establish a constipated habit, but if such fissures 
are common in this country, except in syphilitic infants, they have 
escaped our notice. 

Constipation has a tendency to perpetuate itself, since retained fecu- 
lent matter becomes more consistent and firmer, and the contractile 
power of the muscular tunic becomes weakened by long distention. 
Obviously, also, an abnormal length of the large intestine, so that it 
doubles on itself, whether congenital or the result of constipation, and a 
malposition, which diminishes the space occupied by the colon, and 
therefore increases its flexures, have a tendency to produce constipation. 

Symptoms. — When there is a mechanical cause, which retards the 
passage of fecal matter, the acuteness of symptoms and the suffering are 
generally proportionate to the degree of obstruction. Symptomatic con- 
stipation occurring in an obstructive disease, whether adhesions, perito- 
neal bands, intussusception, knots or twisting of the intestine, incarce- 
ration in a false passage, or from biliary or intestinal stones, or fecal 
masses, is attended by severe symptoms, such as intense colicky pain, 
vomiting, loss of appetite, and rapid prostration. The ingesta accumu- 
late above the point of obstruction, producing distention of the intestine 



756 CONSTIPATION. 

with fecal matter and gas, while below the point of obstruction the in- 
testine is soon empty. The symptoms indeed have the severity, and 
the state involves the danger, present in ordinary strangulated hernia ; 
while, from being internal and therefore less accessible for treatment, 
the danger is even greater. If the intestinal tract be narrowed, whether 
by a false ligament, the result of an old peritonitis, or other cause, and 
there be still perviousness, so that excrementitious matter passes by the 
obstruction, though slowly, and with more or less difficulty, the patient 
may be comparatively comfortable, if the food be such that no hard 
masses remain ; but according to the degree of stenosis and the amount 
and coarseness of the fecal matter, symptoms occur referable to the ob- 
struction. If the excrement be propelled with difficulty through the 
narrowed part, the muscular coat above the obstruction gradually be- 
comes more developed, from hypertrophy of the muscular fibres, just as 
the heart enlarges from obstructive disease of its valves, while below 
the obstruction the intestine atrophies, and its calibre diminishes from 
disuse. Colicky pains, accumulation of fecal matter above the obstruc- 
tion, distention of abdomen, eructation of gas, vomiting, impaired appe- 
tite, and consequent decline of the general health are common results. 
There is constant danger in these cases that the narrow passage may 
become obstructed by fecal matter, if it happen to contain hard masses, 
or coarse indigestible substances. The gravest form of constipation is 
obviously that due to mechanical agencies which act as obstacles, but as 
the obstacles are numerous, differently located, and of different character, 
so there is great difference in the gravity of the cases. 

Idiopathic constipation generally comes on gradually. It at first at- 
tracts little attention and is neglected. The symptoms, of course, vary 
greatly according to the degree and stage of constipation. In mild 
cases, the retention is only in the rectum, or rectum and sigmoid flex- 
ure, and there are no marked symptoms except a sensation of fulness or 
distention of these parts, which one or two evacuations relieve. Be- 
tween these mild cases and the graver forms of constipation, there is 
every intermediate grade, attended by symptoms proportionately severe. 
It is surprising sometimes to observe how long patients live with ex- 
treme constipation, though with constant suffering and ill-health, and, 
which I wish especially to be noticed in this connection, a large propor- 
tion of the fatal cases of idiopathic constipation occurring in adults, 
and recorded in the literature of the profession, began early in life, even 
in infancy, at which time they probably might have been relieved by 
proper medical measures, and a life of suffering prevented. This im- 
portant practical fact shows the need of greater attention on the part of 
parents and nurses to the state of the bowels in children, that their slug- 
gish action may be corrected before it becomes habitual, and those ana- 
tomical changes of distention and muscular paralysis occur, which are 
with difficulty corrected. Thus among the older authenticated cases 
is one related by Dr. Copeland, in his Medical Dictionary, from Re- 
nauldin. 

Case. — A medical officer in the French service was always costive from 
birth, he ate largely, but seldom passed a stool oftener than once in one or 
two months, and his r abdomen assumed a large size. At the age of forty- 



SYMPTOMS. 757 

two, his constipation was usually prolonged to three or four months. In 
1806, after medicines had been taken to procure a stool, which had not 
been passed for upward of four months, abundant evacuations continued 
for nine daj^s, and contained the stones of raisins taken a twelvemonth 
before ; but the constipation returned. In 1809 the enlarged abdomen 
became painful, vomiting supervened, and he died at the age of fifty-four, 
having seldom, through life, passed more than four, five or six stools in 
the year. On opening the abdomen, a fibrous partition obstructed the 
rectum, about an inch from the anus. 

A case quite as remarkable, and of recent date, occurred in the prac- 
tice of Dr. Strong, 1 of Westfield, N. Y. 

Case. — This patient, at the age of two years, usually had one stool in 
two weeks, and several years later only one in six weeks. When an adult 
he was treated by Dr. Strong, who found great distention of the abdomen, 
so that the lower ribs were pressed outward in nearly a horizontal direc- 
tion, and the thoracic organs upward, so that the apex beat of the heart 
was about one inch above the nipple. At this time, months elapsed be- 
tween the stools, the longest intervals being eighteen months and sixteen 
days. Defecation when it did occur lasted from two to four days, and 
was attended by violent gastric and intestinal pain, vomiting, and pros- 
tration. At one of these prolonged stools, forty pounds of feces, resem- 
bling, as it usually did, chewed brown paper, were evacuated, the quan- 
tity being accurately ascertained by weighing the patient before and after- 
ward. He had appetite and was able to do certain kinds of farm work 
during the year preceding his death, which occurred at the age of twenty- 
eight years. At the autopsy the colon was found to have a length of six 
feet and three inches, and a circumference of thirteen inches, while the 
lungs were pressed upward and backward, as when compressed by a pleu- 
ritic exudation. 

While such extreme cases are infrequent, all physicians of experience 
are consulted from time to time by adults who have had habitual consti- 
pation from their earliest recollection, and these cases, that aggregate so 
large a number, might, there is little reason to doubt, have been pre- 
vented for the most part during childhood, when the habit was being 
formed. 

In long-continued constipation, in which there is a large fecal accu- 
mulation, not only is the diameter of the colon increased, as stated 
above, but this part of the intestine becomes elongated. This may lead 
to change in its position, the curves of the sigmoid flexure extending 
further to the right, and the central part of the transverse colon by its 
weight curving downward. This abnormal lengthening and the conse- 
quent curvatures have a tendency to increase the constipation, as has 
been stated above in our remarks relating to the etiology. 

In these cases of extreme constipation, which fortunately are rare in 
children, as they are also in adults, the distention of the colon at the 
ileo-csecal orifice has a tendency to widen this orifice, so that the valve 
which, in the ordinary state, prevents the return of any substance which 
has once passed by it, is liable to become insufficient. The adjacent 

1 Amer. Journ. of Med. Sci., 1874 and 1876. 



758 CONSTIPATION. 

folds which constitute the valve become separated, so that, if vomiting 
and antiperistaltic movements occur, fecal matter may pass from the 
colon toward the stomach. In aggravated cases, in which there is re- 
tention of a large amount of fecal matter, distention, muscular paralysis, 
etc., similar to those which we have seen produced in the colon, are 
liable to occur, though to a less extent, in the small intestines, especially 
in the ileum. 

Retained excrementitious matter accumulating in large masses evi- 
dently becomes an irritant, so that, by its pressure, it excites muscular 
contractions, which, if ineffectual in propelling the mass, cause colicky 
pains. The retained fecal matter also undergoes more or less decom- 
position, producing gases which, by increasing the distention, also 
increase the pain. 

Any irritating substance applied to a mucous surface is liable to excite 
increased secretion from the mucous follicles or from the glands whose 
orifices connect with the mucous membrane at the point of irritation. 
Many familiar examples will at once be recalled to mind, as the defluxion 
from the nostrils from the use of snuffs, and increased mucous secretion 
and salivation from objects held in the mouth. In the same way, re- 
tained excrement, forming hard masses which press upon the intestinal 
surface, excite a secretion, and not infrequently produce thereby a diar- 
rhoea which is conservative, and which may for the time unload the 
bowels, or it may remove a part of the scybalse, while the rest remain. 
Hence we sometimes hear patients speak of having irregular evacua- 
tions, constipation alternating with diarrhoea. In aggravated cases, the 
pressure of impacted feces sometimes produces inflammation of the sur- 
face, when, in addition to abdominal pain, there are tenderness on pres- 
sure and some, usually quite moderate, febrile movement. In cases 
which have terminated fatally, after a longer or shorter time, destruc- 
tion of the mucous surface has been found in places, in consequence of 
the pressure and inflammation. Thus, in the history of the Erench 
officer related above, it is stated that the inner surface of the distended 
intestine "presented gangrenous and ulcerated patches." We can 
readily believe that, as in cases of typhoid ulcerations, if the ulcers 
reach a certain depth, they may also give rise to localized peritonitis, 
and that occasionally perforation may result at the ulcerated or gan- 
grenous point. The expulsion of hardened masses which have collected 
in the rectum is slow and painful, and accompanied by more or less 
tenesmus, which not infrequently causes a portion of the mucous mem- 
brane at the anal orifice to descend below the sphincter ani and pro- 
trude, by which hemorrhoids are produced. Occasionally, as I have 
observed in certain cases, the entire circumference of the rectal mucous 
membrane, to the distance of half an inch or more above the anus, 
becomes so loosened from its attachment to the connective tissue that it 
descends below the sphincter ani, and protrudes during each defecation. 
But this displacement, known as prolapsus recti, more commonly re- 
sults, in children, from protracted intestinal catarrh, attended by diar- 
rhoea, loss of flesh, and by diminished tonicity of the tissues. 

A beautiful and conservative provision in the system is that by 
which vicarious functions are established to relieve organs which imper- 



TREATMENT. 759 

fectly perform their part. While the intestinal surface is to a great 
degree eliminative, so that noxious and effete products are largely ex- 
pelled from the system in the stools, it possesses also, in high degree, 
an absorbent function, as all who employ rectal alimentation are aware. 
Now, if the intestine fail to perform its function of defecation, and fecu- 
lent matter collect within it, and begin to exert pressure upon the intes- 
tinal surface, more or less of the liquid portion is taken up by the ves- 
sels, and, entering the general circulation, finds a mode of escape through 
other emunctories. The general ill-health or languor, the furred tongue, 
headache, and foul breath which characterize these cases are, no doubt, 
due to the absorption into the blood, or retention in it of noxious pro- 
ducts contained in, and which in part constitute, the feculent matter. 
The fact that patients may live for years with tolerable appetite, and 
with only one dejection every second or third week, receives explanation 
in the fact that other organs, as the lungs, kidneys, skin, etc., act as 
depurants for such excrementitious matter as can be taken up in a 
liquid or gaseous form by the intestinal surface. 

In infants, constipation, even when slight and temporary, often 
causes fretfulness, which is indicated by the character of their cries and 
the movement of the thighs over the abdomen. Continuing for a time, 
it causes more or less fever, and, in those young children who are 
liable to eclampsia, it predisposes to an attack, and it may be the 
chief cause. 

Treatment. — If there be reason to suspect the presence of a mechan- 
ical obstacle which prevents normal defecation, a careful examination 
should be made, in order to discover, if possible, its nature and loca- 
tion. Often it is of such a nature that it cannot be removed, but its 
constipating effects may sometimes be in a measure obviated. In the 
case related above, in which constipation continued from early child- 
hood to adult life, and finally proved fatal, its cause was ascertained to 
be a septum in the rectum, which probably might have been relieved by 
surgical measures. In all cases of constipation, which the history 
shows may be produced by mechanical causes, whether the obstruction 
be complete and the colicky pains and other symptoms severe, or there 
be occasional scanty evacuations, with but slight or moderate suffering, 
the history of the patient should be obtained, in order to ascertain if 
there had been at any previous time symptoms of peritonitis or other 
pathological state which might throw light on the etiology. The abdo- 
men and the usual sites of hernia should be carefully explored by pal- 
pation, and the rectum by the finger, large size catheter, or rectal tube. 
A thorough examination thus instituted, painless to the patient, will 
usually enable the practitioner to determine either the exact or probable 
obstacle, if any, be present. 

The proper treatment of symptomatic constipation obviously requires 
the removal, so far as possible, of the primary disease, or the cause, 
whether it be obstructive or otherwise, and we need not stop to consider 
the special measures which are required, and will pass to the considera- 
tion of the treatment of idiopathic constipation. 

Hygienic Measures. — We have already alluded to the fact that habit 
has a powerful control over the action of the intestines, so that it is im- 



760 CONSTIPATION. 

portant to obtain a daily alvine evacuation at a certain hour, and, by 
establishing the habit, the need will usually be experienced when that 
hour arrives each day. Many cases which become troublesome and ob- 
stinate might, no doubt, have been prevented, had this physiological law 
been heeded, and a daily evacuation obtained at a certain hour. The 
constipated habit, mild and not yet fully established, is more liable to be 
overlooked when it occurs in childhood than in infancy, for the infant is 
closely and constantly under observation, and it soon presents symptoms, 
as fever and fretfulness, if it do not have the regular evacuation, while 
children over the age of four or five years tolerate better a sluggish state 
of the bowels, and are likely to be constipated for a considerable time 
before it is ascertained. They therefore require more attention, in this 
regard, than is usually bestowed by parents. 

The nature of the diet is obviously important, as certain kinds of food 
are more laxative than others. Chicken-tea, and, to a certain extent, 
beef and mutton tea, are laxative, and, made plainly, are, therefore, use- 
ful in connection with other articles. The various kinds of berries and 
fruits have also a decidedly stimulating effect on the intestinal surface, 
and aid in removing constipation. The apple scraped or baked, or 
apple-sauce, may be given to quite young children ; and for those that 
are older, currants, cherries, and, among dry fruits, prunes and figs are 
laxative. Unfermented cider, in its season, which has been found so 
useful for adults, may also be given to children in moderate quantity, at 
least to those who have reached the age of two or three years. 

By the digestive process, starch, which is unassimilable, is changed 
into glucose, which can be absorbed and assimilated, and, from the small 
size of the salivary glands in the first months of infancy, it is believed 
that the salivary and pancreatic fluids are insufficient to convert starch 
into glucose except in very inadequate quantity. It appears, however, 
highly probable that there is an epithelial ferment, which converts starch 
into sugar 1 , so that young infants can digest starchy food in limited 
quantity. The belief that the infantile digestion, up to a certain age, is 
inadequate to effect the change, led to the preparation of food for infants, 
in which the change of starch into glucose was accomplished by a chem- 
ical process. Now glucose, given in considerable quantity, is laxative, 
and I have found it necessary to give the glucose preparation sparingly, 
and with other food in the hot months, when infants are so prone to 
diarrhoea. But this laxative effect renders the glucose preparations of 
the shops very useful in the treatment of habitual constipation of infants, 
whether we employ the "maltose" or " granulated sugar of malt," or 
the preparations of Liebig's food. Of four constipated infants in the 
New York Infant Asylum, to whom Horlick's "sugar of malt" was 
given, three were relieved. Any of the glucose preparations can be 
given quite freely to a constipated infant, without impairing the diges- 
tive function, or producing other ill-effect, so long as no more than the 
normal evacuations are produced ; and I consider them among the best 
and safest of the foods for the relief of constipation in infants, but 

1 Chemical Phenomena of Digestion, by Charles Eichet, Eev. des Sci. Med., 
Oct. 1878. 



TREATMENT. 7fil 

glucose or grape sugar is only feebly laxative, probably not more than 
cane sugar. 

Oatmeal is more laxative than most other kinds of amylaceous food. 
Made into a gfuel and strained, it may be given to the nursing infant, 
and unstrained to those who are older. Bread or pudding from coarsely 
ground or unbolted flour or meal, and vegetables which contain saline 
and fibrous substances, have a stimulating and laxative effect on the sur- 
face of the intestines, and, therefore, are useful for constipated children 
of the age of two or three years and upward. 

There can be no doubt that the free use of water in the ingesta mate- 
rially aids in relieving costiveness. In one of the numbers of the Lon- 
don Lancet, a physician asks the profession how to cure obstinate 
constipation in adults. Among the replies, one physician suggests 
drinking a tumblerful of cold water on retiring to bed, and another 
tumblerful in the morning, and there can, I think, be little doubt that 
the laxative effect of broths, gruels, fruits, and mineral waters is partly 
due to the amount of water which they contain. One of the chief 
causes of constipation, we have seen, is too great firmness or consistence 
of the stools, due to absorption of the water, and if a larger quantity 
of water be swallowed during or after the meals than is removed by 
absorption, so that the stools have their normal or less than normal 
consistence, this cause of constipation is removed. An excess of water 
introduced into the system is to a great extent eliminated by the kid- 
neys, and, in hot weather, by the skin, and, to a certain extent, exhaled 
from the lungs ; but experience shows that, if the amount of liquid 
received be so great that the vessels in the coats of the intestines con- 
tinue in a state of repletion, only a certain part of it is absorbed, while 
the rest descends and mixes with the excrementitious matter. 

The simple expedient of allowing a liberal use of water, so useful in 
adult cases, doubtless also has a laxative effect in children, and its judi- 
cious use is proper for them. Another important aid in overcoming 
habitual constipation is frequent kneading of the abdomen. My atten- 
tion was first particularly directed to this in the treatment of the case 
related above, in which obstinate constipation, occurring in a child of 
three years from peritoneal bands and adhesions, was to a great extent 
corrected by friction over the abdomen for three or four minutes at a 
time with cod-liver oil, three or four times daily. The manipulation 
probably did the good, and not the oil, but the use of one of the oils for 
inunction renders the kneading less painful, and insures its more 
thorough performance by the nurse. All obstetricians in certain emer- 
gencies stimulate the uterine muscular fibres to contraction by kneading 
the abdomen, and it is probable that the muscular fibres of the intes- 
tines are stimulated in a similar manner, so that the intestinal move- 
ments are increased by which feculent matter is carried forward. 

The external application of cold, so effectual in contracting the uter- 
ine muscular fibres, also stimulates the contractile power of the muscular 
fibres of the intestines. Cold-water bathing, the sudden application of 
a cloth wrung out of cold water to the abdomen, and in certain ob- 
stinate cases even the douche, may be used to stimulate the muscular 
coat of the intestines and the abdominal muscles to greater activity. 



762 CONSTIPATION. 

Trousseau says: "Before leaving the subject of the treatment of con- 
stipation, let me refer to the application of cold to the abdomen — a 
minor method, which I have seen recommended, and have myself pre- 
scribed with astonishing success. On rising in the morning, let there 
be placed on the abdomen a compress of several folds soaked in cold 
water, and let it be separated from the clothes by a sheet of gutta-percha 
or caoutchouc. This compress ought to remain on for three or four 
hours." This recommendation by Trousseau is for adults, who are 
much less susceptible to the influence of cold than children. So pro- 
longed an application of cold and wet to a child, even the most robust, 
would involve danger, while its application during the brief period oc- 
cupied in an ordinary bath, with proper exercise afterward, or with 
other measures to prevent chilling, could have no ill-effect. 

Therapeutic Measures. — For temporary constipation and many cases 
that are habitual, enemata should be employed, since they promptly un- 
load that part of the intestines in which feculent matter is ordinarily 
retained, while they do not impair the appetite or produce the prostra- 
tion which so often results from purgatives. For temporary constipa- 
tion, a warm clyster may be given, and it commonly is more agreeable 
to the patient than one of lower temperature than the body. Among 
the enemata which have been found useful are castile soap, with molas- 
ses and water, salt and water, the various oils, as sweet oil, with or with- 
out castor oil, linseed oil, alone or with molasses, and the gruels, as that 
of oatmeal or cornmeal made thin. The belief that the frequent use 
of warm clysters produces a relaxing effect is probably correct, so that, 
if it be necessary to employ clysters often, in consequence of the torpid 
state of the intestines, cool water, the effect of which is tonic and stimu- 
lating, should be used. 

For infants, a clyster of one or two ounces usually suffices, adminis- 
tered by a gutta-percha or glass syringe, while for older patients a pro- 
portionately larger quantity is required, administered by preference 
through a Davidson, India-rubber, or a fountain syringe. In certain 
long-continued, aggravated cases, the frequent injection of a large quan- 
tity of tepid water is indispensable, in order to wash away the accumu- 
lation of fecal matter. Thus, in 1854, Mr. Gay exhibited to the London 
Pathological Society a boy of seven years, who at the age of three years 
had had typhus fever with dysenteric stools. After convalescence, he 
had habitual obstinate constipation, so that, when Mr. Gay began treat- 
ment, there had been no fecal evacuation for nearly four months, and 
the girth of the body over the abdomen was forty-nine inches, and yet 
the appetite and general health were not seriously impaired. The shape 
of the abdomen and the examination showed great distention of the 
rectal ampulla and the descending colon. Mr. Gay first distended the 
sphincter ani, so that it admitted a speculum, and through a rectal tube, 
well introduced into the colon, the excrement was repeatedly washed 
away, so that at the time of the exhibition of the boy to the Society, the 
measurement in girth gave only twenty-four inches. Evidently in cases 
like the above, no other treatment except repeatedly washing out the 
intestines with warm water would have answered, and the dilatation of 



TREATMENT. 763 

the sphincter ani and the introduction of the speculum to facilitate the 
escape of fecal matter are noteworthy. 

Suppositories may sometimes be usefully employed in place of ene- 
mata; cocoanut butter, molasses candy, or soap cut in shape of a pencil 
may be used for this purpose. In the adult, long-continued constipa- 
tion is not very rare, in which the rectal ampulla becomes so impacted 
that it is necessary to use the anal curette, the handle of a spoon, or the 
finger introduced, in order to break up the masses, and allow them to 
pass. In children, necessity for such treatment is much more rare, but 
there are occasional cases like that above described by Mr. Gay, in 
which it may be needed. Dr. Nagel states that the evil may be removed 
by the introduction of a suppository of brown gelatine. This is steeped 
in water for twelve hours, and having been thus softened, is introduced 
into the rectum, and an evacuation obtained. The doctor attributes the 
laxative effect to the hygrometric action of the gelatine. 

The known effect of the galvanic current in producing contraction of 
the uterine muscular fibres suggests its employment to relieve constipa- 
tion, by stimulating the muscles of the abdomen and the muscular coats 
of the intestines, and those who have employed it speak favorably of its 
use. Habershon savs: ".A galvanic current, transmitted through the 
abdominal walls, induces a very speedy action, or rather emptying of 
the colon. ... A case of partial paraplegia, in which injections 
did not act satisfactorily, and drastic purgatives were undesirable, was 
treated by a galvanic current passed through the abdomen every morn- 
ing. In a few hours a free evacuation was produced without any dis- 
comfort." But the constipation of children very seldom requires the 
use of galvanism. 

The ordinary purgatives should not be given habitually to relieve a 
constipated habit. They are liable to irritate the intestines, causing a 
catarrh, or else the intestines become accustomed to their action, and a 
large dose is needed to effect purgation. Given habitually, they cannot 
fail, also, to disturb the digestive and nutritive processes. One or two 
doses for present relief, both in habitual or temporary constipation, is 
sometimes required, provided that an injection is for any reason not 
preferred. -^Tor this purpose, castor oil or a few grains of calomel mixed 
with syrup of rhubarb, the syrup of senna, or the compound liquorice- 
powder of the German Pharmacopoeia may be administered with ad- 
vantage. But for habitual constipation I strongly advise to discard the 
ordinary purgative medicines, and if the measures of a dietetic or 
hygienic character, recommended above, are not sufficient, to employ 
such remedial agents as promote, or at least do not impair, nutrition. • 

Belladonna, so highly recommended by Trousseau and others, I have 
often administered to children, especially in pertussis, in large doses 
during several consecutive days, but it has not seemed to me to have 
any decided laxative effect. Though it may be useful in certain mix- 
tures for adults, our experiences in this country, with reliable prepara- 
tions, certainly have not been such as to justify its employment as the 
sole or main remedy for constipation. It diminishes reflex irritability, 
and may render the action of purgatives less painful, but from its known 
physiological effects we cannot believe that it increases the intestinal 



764 CONSTIPATION. 

secretions or the action of the muscular fibres, one or the other of which 
results we expect from the use of an agent which is really laxative. On 
the other hand, nux vomica and its active principle, strychnia, are 
doubtless valuable adjuncts to purgative mixtures, from their effect in 
increasing the action of muscular fibres. 

Physicians are not infrequently at a loss what to prescribe for the 
habitual constipation of nursing infants, which is by no means infre- 
quent. But recollecting that the colostrum is more laxative than ordi- 
nary milk, and that it differs from it in containing more sugar, salts 
(largely phosphates), and butter, we have a hint, as stated above, as to 
what is probably lacking in the milk, and what, therefore, should be 
supplied. I am in the habit of giving the oil, sugar, and salts in the 
following formula, and usually with the desired laxative effect : 

R . — 01. morrhuse 2 parts. 

Aq. calcis, 

Syr. calcis lactophos. . . . . . . aa 1 part. 

One-quarter, one-third, or one-half teaspoonful may be given with 
each nursing, or a larger quantity, as a teaspoonful or more, three times 
daily. Breast-milk with this addition becomes more nearly like colos- 
trum in its laxative properties, while it does not possess those properties 
of colostrum which disturb the digestive process. I know no agent of a 
medicinal nature which meets the indication so well as this for infantile 
constipation. But in my practice I have found it necessary, in not a 
few instances, to rely mainly on simple enemata for the relief of the 
constipated habit, till the infants reached the age when a mixed diet 
was proper. 

The habitual constipation of older children may ordinarily be relieved 
by the remedies recommended above, but occasionally a more active 
purgative effect may be needed. Since the portion of intestine which 
is chiefly implicated in ordinary forms of constipation is the colon, it is 
evident that, if it be necessary to employ frequently any of the active 
purgatives of the pharmacopoeia, such should be selected as produce 
little or no irritation of the long tract of the small intestines, while they 
stimulate the function of the colon. The aloetic preparations are pre- 
ferable for this purpose, as the tincture of aloes and myrrh, or the 
simple tincture of aloes, which may be given in close of part of a tea- 
spoonful in a convenient syrup, or in coffee or milk. 



INTESTINAL WORMS. 765 



CHAPTEE XI. 

INTESTINAL WORMS. 

The belief has been prevalent in the profession in former times, and is 
now among the people, that worms in the intestines constitute a frequent 
disease, especially in children. As pathology and the means of diag- 
nosticating diseases are better understood, this idea has been gradually 
abandoned by physicians and the intelligent portion of the community. 
Still these parasites must be considered an occasional pause of serious 
derangements, and, in rare instances, a cause even of death. They 
indeed often exist in small number, without producing any appreciable 
deviation in the individual from the healthy state ; but the most common 
and best known species, when they have once effected a lodgement in the 
intestines of man, ordinarily grow and multiply so as to produce symp- 
toms, and require medicines for their expulsion. 

So far as is now ascertained by observations in different countries, 
about fifty animal parasites make their abode in man. It is not im- 
probable that the number will yet be found greater by observations in 
distant uncivilized countries. Of these fifty, twenty-one reside in the 
alimentary canal (Heller), several of them being microscopic. Of those 
occupying the intestines only, the following species are specially inter- 
esting to the practising physician, on account of their relation — for the 
most part causative — to certain pathological states, to wit : the ascaris 
lumbricoides, or round-worm; the oxyuris vermicularis, or thread- 
worm ; the bothriocephalus latus, and three species of taenia, or the 
tape-worms, and the trichocephalus dispar, or whip-worm. 

Ascaris Lumbricoides. — The round-worm has a dingy reddish or 
yellowish-red color and a cylindrical form, tapering toward both ex- 
tremities from the point of its greatest diameter, which is a little poste- 
rior to the middle. The dead worm is paler than the living. The 
anterior extremity is tipped with three tips, between which and the 
body is a circular groove. Between these three tips anteriorly is the 
aperture of the mouth, from which the oesophagus extends to the dis- 
tance of one-fourth to one-third of an inch. The intestine, which has 
a light brownish color, extends from the oesophagus to near the poste- 
rior extremity of the animal, where it terminates in the anus. The 
females are in numerical excess of the males, and their size is also 
greater. The shape of the worm is like that of the common earth- 
worm, from which it derives the name lumbricus, but it is somewhat 
more pointed and its color paler red. The tail of the male worm is 
curved like a hook, while that of the female is straight. 

The total number of eggs contained in a fully developed female has 
been estimated at sixty millions. The eggs when immature are conical, 
and are attached to a longitudinal band ; when mature they are oval, 



766 INTESTINAL WORMS. 

with dark granular contents and a strong double shell, and their diam- 
eter is about -g-J-Q of an inch. They are expelled in countless numbers 
ay i th the feces, and at the time of expulsion are surrounded by an albu- 
minous coating stained with bile. Their vitality is retained under 
apparently very unfavorable circumstances, even for years. They 
hatch after they have been repeatedly frozen or desiccated. 

The ascaris lumbricoides inhabits the small intestines, where it is 
rapidly developed from the embryonic state. The remark made by 
Heller, that when found in the colon it is always dead, cannot be true, 
for many live worms are expelled in the stools. 

The round-worm, more than all other intestinal worms, is inclined 
to wander away from its usual abiding- place, namely, from the jejunum 
and ileum, producing symptoms of more or less gravity, referable to 
the part over which it crawls. It occasionally enters the stomach, 
from which it is vomited, or it ascends the oesophagus into the fauces, 
from which it is soon removed by the efforts of the individual. Cases 
are on record, one of which Andral witnessed, in which the worm en- 
tered the larynx, producing suffocation and speedy death. Mr. Ton- 
nelle also witnessed such a case. A child, nine years old, was suddenly 
seized with great difficulty of respiration and pain in the upper part of 
the chest. A careful examination of the thorax gave a negative result. 
Death occurred in from twelve to fifteen hours, and at the post-mortem 
examination a lumbricus was found filling the cavity of the larynx. M. 
Blandin, also, witnessed a case, when interne of the Hopital des En- 
fants. An infant was suffocated by one of these worms, which had 
penetrated as far as the right bronchus. Very rarely they crawl from 
the fauces into the nasal passages. This worm is so strong and active 
that there is no recess or reflexion of the mucous membrane of the 
digestive apparatus which it could possibly penetrate, in which it has 
not been found. It has been discovered in the appendix vermiformis, 
in the pancreatic duct, in the common bile-duct, and even in the gall- 
bladder. The number of these worms found in the intestines is very 
various. There may be only one, or the number may be incredibly 
large. 

Thus, Barrier relates the case of an infant thirty months old, who 
died in Hopital Necker. It was believed to be tubercular. Numerous 
tumors, which could be felt in the abdomen, were supposed to be tuber- 
cular masses. On making the post-mortem examination, the mesen- 
teric glands were found healthy, but the intestines throughout their 
entire extent were filled with lumbrici. The masses which, during life, 
were supposed to be tubercular glands, were found to consist of worms. 
The csecum, especially, was greatly distended by them. The inter- 
twining or collection in balls of these worms constitutes, indeed, one of 
the chief dangers, as it renders them so much the more difficult of 
expulsion. 

The round worm possesses no organs of penetration ; still, if the 
intestine be weakened by disease, especially by ulceration, it may, by 
pressure with its head, force an opening, through which it escapes into 
the cavity of the abdomen, causing peritonitis and death. This worm 



INTESTINAL WORMS. 767 

is commonly found, whether single or in masses, surrounded by mucus, 
which serves as a partial protection to the intestines. 

The portion of the mucous membrane in contact with lumbrici is 
often found inflamed, either from movements of the worm, or from 
pressure of a mass of worms, or even of a single worm in a confined 
position, as the appendix vermiformis. This inflammation, continuing 
and increasing, may end in ulceration, and thus a weakened spot be 
produced, which may be ruptured by simple pressure of the mouth of 
the worm. In this way are to be explained those apparent cases of 
perforation which have led some observers to believe that lumbrici have 
actually the power of penetrating the healthy coats of the intestines. 
The perforation is obviously most liable to occur in those who have been 
enfeebled, and whose tissues have been rendered less firm and resisting 
by antecedent disease, as by typhoid fever. 

M. Guersant describes a case in which the appendix vermiformis 
contained an ulcerated opening, through which two round-worms had 
partly passed into the abdominal cavity, producing fatal perityphlitis. 
The effect of their impaction in this narrow cul-de-sac was much like 
that of a bean or seed lodged in the same situation. 

The ascaris lumbricoides has occasionally been found in the most 
remarkable locations, namely, in abscesses lying without the intestines. 
They have been known to effect a lodgement in the liver, and produce an 
abscess there, no doubt by crawling up and distending a bile-duct. 
Their lodgement in other viscera, which have no pervious connections 
with the intestinal tract, is probably accomplished through fistulous 
openings produced by inflammation which they had no part in causing, 
as, for example, in the bladder and kidneys, of which there are well- 
authenticated cases. Worm cysts in the abdominal walls have been 
found to occur in most instances in the usual site of hernias, namely, at 
the umbilicus in children, and in the inguinal region in adults. It is 
presumed, therefore, that the worms had entered hernial protrusions, 
from which they had passed by ulceration into the abdominal walls, and 
had there become encapsulated. 

The oxyuris verrnicularis, or thread-worm, so called from its resem- 
blance to pieces of ordinary white sewing thread, is also frequent in 
childhood, and not infrequent in the adult. The length of the male 
oxyuris is from one-sixth to one-fifth of an inch ; that of the female 
from one-third to one-half an inch. The posterior extremity of the 
male is blunt, and is curved, or rolled up, toward its abdomen ; that 
of the female is slender and pointed like an awl. 

The head of this worm is relatively broad, from an unusual thickness 
or fulness of the cuticle, and the mouth, surrounded by " three nodular 
lips," is situated in the centre of the extremity. The oesophagus ex- 
tends backward from the mouth, gradually growing larger, like the seg- 
ment of a long and narrow cone, and ending in a globular enlargement, 
which has been designated the pharynx. From the pharynx the intes- 
tine runs in nearly a straight line through the worm. 

The eggs are numerous, so completely filling the interior of the female 
as to conceal the organs from view. They are flattened on one side, but 
are rounded or convex on other parts of their circumference. One end 



768 INTESTINAL WORMS. 

is more pointed than the other, as in the eggs of birds. Certain of the 
eggs in the mature female are seen to be undergoing segmentation pre- 
paratory to hatching, while others more advanced contain tadpole- 
shaped embryos, and others still contain worm-shaped embryos, either 
lying within the shells or protruding from them. The hatching and 
growth of this worm, which have been observed under the microscope, 
are very rapid under favorable circumstances. "I once," says Heller, 
" saw the metamorphosis from the tadpole-shaped embryo to the worm- 
shaped embryo completed in about one hour," but the usual time is 
longer. Leuckhart saw oxyurides, one-fourth of an inch in length, 
fourteen days after the eggs had been swallowed. 

Oxyurides may be developed so rapidly from eggs swallowed in the 
ingesta, that they attain nearly or quite their full growth while still in 
the small intestines, so that, although their chosen residence is in the 
large intestines, some of them are not infrequently found in the ileum, 
and even in the jejunum, of full size and active. The part of the intes- 
tinal tract which the oxyurides prefer, and in which the largest colony 
of them reside, is the caecum and appendix vermiformis, and not in the 
rectum, as stated in most of the books, and in this situation, where they 
have been little disturbed, their habits and the relative proportion of the 
sexes can be best observed. But they are ordinarily found both in the 
caecum and rectum in the same individual, and, indeed, upon all parts 
of the intervening surface of the colon. 

The number of oxyurides in the individual varies greatly. They are 
occasionally so numerous upon the intestinal surface that they resemble 
fur, and when they are so abundant they are commonly found above the 
ileo-caecal valve as well as below it. The males are smaller and appar- 
ently more fragile and perishable than the female. Therefore in the 
rectum and other exposed situations, there is a numerical excess of the 
females ; but in reflexions of the intestines, where they are securely 
lodged, as in the appendix vermiformis, no marked difference has been 
observed in the relative number of the two sexes. Since the males are 
more delicate, transparent, and smaller than the females, they are more 
likely to be overlooked in a hasty post-mortem examination. 

The term tape-worm is applied to several species of the taenia, and to 
at least two species of the bothriocephalus, but all except four, to wit, 
the taenia solium, taenia saginata or medio-canellata, taenia elliptica or 
cucumerina, and the bothriocephalus latus, are rare in Europe and 
North America, and are therefore of little interest to the practising 
physician. 

The tape-worm is an hermaphrodite, each segment containing the two 
sexual organs. The head, or scolex, is small, about the size of a pin's 
head, and segment after segment is produced by a budding process from 
the head. The segments are attached to each other at their extremities, 
and each segment as it becomes further and further removed from the 
head, by the formation of new intervening segments at the upper end 
of the chain, becomes also larger and more matured. The oldest seg- 
ments having attained their full growth, are detached, and have an in- 
dependent existence. A separation of the chain of segments at any 
point does not compromise the life of the parasite. If only the head 



INTESTINAL WORMS. 769 

remain uninjured the segmentation continues from it, and in time the 
former number of segments and former length of the chain are restored. 
This worm resides in the small intestines, the larger species sometimes 
extending from the upper part of the jejunum to near the ileo-caecal 
valve. 

The tcenia solium is developed from an embryo, known as the cysti- 
cercus cellulosae, contained in the muscles of the hog. It has also been 
found in some other animals, as the dog, deer, and polar bear. It is a 
vesicle, about the size of a pea or small bean, having a delicate cell-wall, 
and is nearly spherical, except as its shape is changed by compression 
between the muscular fibres. At one point of the cell-wall is a depres- 
sion, attached to the inner surface of which, and lying within the cyst, 
is a whitish, pear-shaped, solid body, which is the head of the cysti- 
cercus, and is identical in appearance and character with the head of 
the taenia solium turned inside out. Many experiments have shown 
the close relationship of the cysticercus and taenia solium, that they are 
two forms of existence of the same parasite. Segments of the taenia 
solium have been repeatedly fed to pigs, and the cysticercus produced 
in their muscles, though in what way the ovum or embryo passes from 
the stomach to the muscles is not known. On the other hand, swine 
flesh containing cysticerci has been fed to animals who were soon after 
killed, when the taenia was found in their intestines. It is evident that 
this parasite occurs only in those who eat swine flesh, as sausages, either 
raw or but slightly cooked. 

The head of this species of taenia, which is about the size of a small 
pin's head, has at the top a conical protuberance, upon which is a 
corona of hooklets, arranged in two circles, the booklets of the outer 
circle being smaller than those of the inner. The projecting points, 
however, of the two rows fall together, forming one circle. The hook- 
lets are inserted into depressions in the head, and many of them have 
fallen out in most specimens which we have an opportunity of exam- 
ining. The depressions in which the hooklets are lodged are often dark 
from pigmentation. Back of the circle of hooks are four sucking disks, 
which the worm is able to protrude and move freely. When protruded 
they appear as small tubercles with slender pedicles. The neck, which 
is slender and about one inch in length, shows markings from com- 
mencing segmentation, and it is succeeded by very small and delicate 
segments, which gradually increase in size as the distance from the head 
increases. 

The mature segments (proglottides) vary in size accordingly as they 
are in a state of contraction or relaxation. When relaxed, their length 
is about half an inch and breadth one-quarter of an inch. The genital 
organs are situated on the margin of each segment, a little posterior to 
the middle, and there is an alternation in their location between the 
right and left margins in the chain of segments. The uterus lies in the 
centre of the segment, forming a longitudinal straight line. From 
seven to twelve branches are given off from each side of the uterus, and 
these divide and subdivide like the branches of a tree. The male genital 
organs lie in the same aperture or pore in the margin of the segment, 
with which the uterus and ovaries connect. 

49 



770 INTESTINAL WORMS. 

The eggs of the taenia solium are globular, with a diameter of about 
73-jj-th of an inch, and with thick shells, which are striated like Mosaic 
work by lines which cross each other. It is estimated that not less than 
50,000,000 eggs are contained in ail the segments of a matured taenia. 

This parasite is very liable to abnormal development. In some in- 
stances two or more segments are fused together, and often they are 
stunted in their growth, or they contain holes, fissures, and flaws, either 
from their original development, or produced by rupture of the dis- 
tended uterus. Again, rarely two taenia are blended, so that along the 
flat side of one chain another is united by the margin, so that a section 
of the double parasite resembles the Roman letter T or Y. The 
nutrition of the segments is maintained through a vessel running the 
whole length of the worm, near each margin, and having communicating 
branches. 

The taenia saginata, designated also medio-canellata, is much larger, 
stronger, and thicker, both as regards the head and segments, than the 
taenia solium. When fully matured it measures eighteen feet. The 
diameter of the head is nearly one line (y-j^j- inch). It is furnished 
with four strong sucking disks, but it lacks the circlet of hooks which 
characterize the taenia solium. Instead of the hooks the head is fur- 
nished with a small frontal sucking disk. The heads of some specimens 
of this worm are free from pigment, but other specimens present various 
shades of pigmentation — from a slight staining to a jet black color. 
The neck is short, and very near the head are markings which indicate 
commencing segmentation. The matured segments vary in measure- 
ment when relaxed — from a length of eight lines and breadth of two 
lines, to a length of nine lines and breadth of three lines. As in the 
taenia solium, the genital pores are situated on the margins of the seg- 
ments, varying irregularly from side to side, and the uterus has lateral 
branches, which divide dichotomously. There is but little difference 
in the sexual apparatus of the taenia solium and taenia saginata, but 
the eggs of the latter are somewhat larger than those of the former, 
and are oval. 

The development of the taenia saginata is sometimes irregular, pro- 
ducing monstrosities, as in the taenia solium. The embryos of this 
parasite occur chiefly in the muscles of ruminating animals, as the ox, 
sheep, goat, etc., and therefore its presence in man is attributable to 
the use of the flesh of these animals, either slightly cooked or raw. The 
cysticercus of this species appears to be less tenacious of life than that 
of the taenia solium, and when it perishes it becomes changed into a 
greenish-yellow pulp, surrounded by the capsule, and imbedded in the 
muscular or other tissue where it had lodged. 

It is easy to distinguish this worm from the taenia solium if the head 
be found, by its larger size, the larger size of its sucking disks, and the 
absence of the circle of hooks. The segments are distinguished by 
their greater size, and the greater number, and the dichotomous division 
of the branches of the uterus. This species occurs over a much greater 
area of the earth's surface than the taenia solium. 

The tcenia elliptica or cueumerina is a more delicate worm than the 
preceding species, measuring, when fully grown, from seven to ten or 



INTESTINAL WORMS. 771 

eleven inches in length. Upon its head is a rostellum or beak, which 
the worm is able to thrust forward, and on which are about sixty hooks, 
irregularly arranged. The anterior portion of the parasite is very deli- 
cate, like a thread, and its segments are small, but, as in the other 
species, they become larger as their distance from the head increases. 
The matured segments which have a reddish- white color are readily de- 
tached, and when separated they move about actively. This taenia is 
also an hermaphrodite, and a genital pore containing a double set of 
genital organs is located on each margin of the segment. The taenia 
elliptica inhabits the small intestines of the dog and cat, and many chil- 
dren in different localities have been affected with it. 

Heller states that the segments of another and rare species of taenia, 
which were expelled from a child of nineteen months, are preserved in 
the Museum of Pathological Anatomy in Boston. Nearly in the mid- 
dle of the posterior half of each segment, is a yellow spot, namely, the 
receptaculum, full of ova, and, therefore, the name flavo-punctata has 
been applied to this worm. Little is known in regard to the taenia nana 
and taenia Madagascariensis, since they occur in distant countries. 

The bothriocephalic latus is the largest of the tape-worms, attaining 
the length of 15 to 24 feet. It is one of the most important of the in- 
testinal parasites. The head has an almond-shape or the shape of an 
elongated and somewhat flattened globe, its length being about one line, 
and its diameter from one-third to one-half a line. Running longitudi- 
nally along each flattened side of the head is a groove or fissure, con- 
taining the apparatus of suction. Those segments which are still in 
the process of growth, have a breadth three or four times greater than 
their length, while the matured segments are nearly square. The gen- 
ital pore occurs in the centre of one side of the segment, and in the 
chain of segments all the pores are found on the same side. A brownish, 
rosette-shaped spot is observed at the site of each ripe pore produced by 
the convolutions of the uterus, and the numerous eggs which this organ 
contains. 

The egg, which is oval, has a thin shell, a light brown color, and at 
one end of it is a lid or operculum, which is separated from the rest of 
the egg by a well-defined line. At the hatching an embryo, provided 
with six hooks, escapes from the lid. When it has separated from the 
egg it is provided with an albuminous covering, from which cilia radiate 
in all directions, by the movement of which it is propelled. After a few 
days this covering is lost, and the embryo now moves about by amoeboid 
extension and contraction. It is believed that in this embryonic state it 
enters an aquatic animal, a mollusk or fish, where it undergoes further 
development, and from which it is received into the stomach in the food. 

The bothriocephalus occurs not only in man, but also in some of the 
domestic animals which eat fish, as the dog. This parasite is believed 
to be rare outside of Europe, and in Europe it is chiefly met in countries 
borderino; on inland lakes and seas. 

The trichocejihalus dispar is comparatively unimportant to the phy- 
sician, since it is uncertain whether it materially impairs the health or 
produces symptoms. It inhabits the caecum, but in rare instances it has 
been found in the ileum and appendix vermiformis. The number of 



772 INTESTINAL WORMS. 

these parasites is usually small, but as many as seventy to one hundred 
have been observed in the intestine of the adult. 

The trichocephalus dispar occurs also in the monkey, and a very 
similar, if not identical, worm has been found in the pig. It is not fre- 
quent in children, and it has not been observed in very young children. 
It occurs in man in every part of the globe, and in some countries, as 
Egypt, Nubia, and Syria, it is said to be very common. This worm, 
which is also sometimes designated the whip-worm from its shape, attains 
the length of one and a half to two inches, the female being longer than 
the male. Its anterior two-thirds are thin, delicate, and flexible, like a 
small thread. The posterior one-third, which contains the generative 
organs and intestinal canal, is considerably thicker, and it ends abruptly. 
On the under surface, extending nearly the whole length of the body, 
is a longitudinal band, the width of which is about one-third the cir- 
cumference of the body. In the female, the posterior or thick portion 
of the worm is slightly bent or curved like the stock of a hunting-whip, 
while that of the male is rolled in the spiral form. The digestive tube 
consists of an oesophagus, which extends through the anterior thread-like 
part, and the stomach and rectum which lie in the posterior thick 
division. The genitals of the female lie in the commencement of the 
thick portion, and the uterus, when distended with eggs, occupies nearly 
the whole of this section. In the male, the pore, which contains the 
genitals, lies in the posterior extremity of the thick part, where it forms 
a cloaca with the termination of the intestinal canal. The eggs, which 
are numerous, are oval, broAvnish, and with a glistening protuberance at 
each extremity, giving them the shape of a lemon. They have great 
vitality, hatching after repeated desiccation and freezing. Their de- 
velopment from the egg is slow. It is believed that the trichocephalus 
is produced directly from the egg, which has lodged in the intestine, 
and, therefore, does not have or require an intermediate stage of prep- 
aration in another animal. This parasite resides in the caecum, but 
when many are present, some are found in the ascending colon, and 
occasionally a few are observed in the small intestine. 

The taenia is rare in early life, but it now and then occurs in young 
children. I have met cases in this city under the age of five years. 
Rosen and Bremser report cases between the ages of six and eleven 
years, and Hufeland one at the age of six months. Wawruch collected 
206 observations of taenia, in 22 of which the age was less than fifteen 
years ; the youngest was a girl of three years. A most remarkable case 
of taenia is reported in the G-azette Medieale of Paris in 1837. M. 
Muller was called to treat a foster child five days old for slight consti- 
pation. The bowels were evacuated by the use of rhubarb, manna, 
and a few grains of salt, and in the excrement a foot and a half of 
taenia were discovored. This worm had evidently existed during the 
foetal life of the infant. 

A similar case was treated by Prof. Skene, in the Long Island Hos- 
pital, in September, 1871, and reported by Dr. Armor. 1 The infant 
was born September 3d, of a hearty Irish servant girl. On the 7th it 

1 New York Medical Journal. 



INTESTINAL WORMS. 773 

refused to nurse, and was observed to have a mild form of tetanus. On 
the 8th small doses of calomel having been given, followed by castor 
oil, two segments of a taenia solium were passed from the bowels, and 
on subsequent days ten more segments, after which the tetanus ceased. 
The remedies employed after September 8th were the oil of male fern 
and turpentine. The mother, who had presented no symptoms of 
taenia, was ordered an emulsion of pumpkin seeds, which " she faith- 
fully took for twenty -four hours, at the end of which she passed over 
seventy segments of taenia. " This case is interesting as throwing light 
on a possible mode of the production of taenia, quite different from the 
ordinary and recognized mode, and also as showing the causative rela- 
tion of intestinal worms to tetanus infantum. 

Causes. — It is obvious that intestinal worms are developed from eggs 
or embryo, which are introduced into the stomach in the ingesta. The 
eggs of the ascaris lumbricoides have been found by Mosler 1 in drinking 
water, but it is probable that in most instances they are contained in 
fruits and vegetables which are eaten raw. The eggs of the oxyuris 
vermicularis are received from some one who is himself affected with 
the disease. Both Zender and Heller state that they have frequently 
discovered ripe eggs of this worm around the nails of persons who were 
troubled with oxyurides, a fact readily explained from the itching which 
they cause. If these eggs are upon the fingers of the mother or nurse, 
it is easy to understand how they are acquired by the child. We can 
understand also why this worm is so common in degraded and filthy 
families. In reference to the etiology of the tape-worm nothing need 
be added to what has been stated above, and little is known in reference 
to the manner in which the eggs of the trichocephalus are received. 

Certain conditions of the intestinal surface favor the occurrence of 
worms. Thus children in advanced typhoid fever are not unfrequently 
affected with the ascaris lumbricoides. 

Symptoms of the Ascaris Lumbricoides. — These are in part con- 
stitutional, and in part local, due to the mechanical effect of the entozoa 
on the coats of the intestines. Writers, especially Rilliet and Barthez, 
have described with minuteness the symptoms supposed to indicate lum- 
brici. Those of a constitutional character are the following : Features 
at one time flushed, at another pallid, and in some children of a leaden 
hue; lower eyelids swollen, and sometimes surrounded by a blue semi- 
circle; thirst, nausea, or even vomiting; appetite diminished or aug- 
mented, or variable ; breath foul ; papillae of the tongue red and pro- 
jecting; pulse accelerated and irregular. Rilliet and Barthez state 
that they observed this irregularity of the heart's action in a boy three 
years old, at the time he was passing a large number of lumbrici. The 
irregularity afterward disappeared. Acceleration of the pulse and in- 
crease in temperature are common symptoms of these worms, and hence 
the popular belief in a worm fever. This fever is often remittent and 
mild, but occasionally it is continuous and of a high grade. 

The symptoms pertaining to the nervous system are important. In 
mild cases these may be absent, as when there are few lumbrici, and 

1 Virchow's Archiv, 1860. 



774 INTESTINAL WORMS. 

the child is robust, and over the age of five years, but in severe cases 
certain neuropathic symptoms are frequently present, such as dilatation 
of the pupils, especially inequality of dilatation, to which Munro 
attached diagnostic value, strabismus, twitching of the muscles, clonic 
convulsions, somnolence, headache, neuralgic pains, delirium. Rarely 
chorea, deafness, and paralysis, it is believed, may result. 1 Dr. 
Leedom, 2 of Montgomery County, Pa., relates the case of a boy of seven 
years, who had night-blindness due to a large number of lumbrici in the 
intestines. By the employment of pinkroot and calomel these were 
expelled, and the blindness ceased. Hyperesthesia of the abdominal 
surface was present in a case which I attended, and which subsided as 
soon as the lumbrici were expelled. Grinding the teeth in sleep, and 
picking the nostrils, are symptoms to which families attach great value. 
Observations, however, show that, though sometimes due to worms, they 
more frequently have another cause. 

The local symptoms or disorders, in other words, those having a 
mechanical origin, are colicky pains, experienced chiefly in the umbilical 
region ; stools sometimes natural ; in other cases diarrhoea with fecal or 
muco-sanguineous stools ; flatulence. M. Davaine, at a recent period, 
made the important discovery that the feces of patients affected with 
worms contain the ova of the particular species present, in large num- 
bers. These ova, which have been described above, can be seen 
through a lens magnifvino; 150 diameters. 

In exceptional cases there are local symptoms, due to the presence 
of these worms in unusual situations, such as a crawling sensation in 
the oesophagus ; a sense of constriction in this tube or the pharynx ; 
nausea and vomiting ; a cough, especially if the worm have crawled to 
the upper part of the oesophagus ; rarely the most urgent dyspnoea, 
and probable suffocation, if a lumbricus have entered the larynx. Ear- 
ache, and perhaps convulsions if the worm have entered the Eustachian 
tube (Case, Davaine, p. 144). The most dangerous symptoms arise 
from the crawling of the worm into narrow openings, 

The enteritis and colitis, to which these worms sometimes give rise, are 
ordinarily mild, but in rare instances ulceration occurs, which may be 
attended by profuse and even fatal hemorrhage. Occasionally very 
painful and dangerous constipation results from an accumulation of 
worms, in a ball or mass too large to be expelled, unless with much 
delay and suffering, preventing the passage of fecal matter, and pro- 
ducing severe abdominal pains. The symptoms in these cases resemble 
closely those of intussusception. A marked example of constipation 
produced in this way occurred in a family with whom I am acquainted, 
and who then resided in the interior of this State. A little girl of three 
or four years was suddenly affected with obstinate constipation. The 
physicians prescribed active purgatives, calomel among others, and 
finally croton oil, and various injections, without relief. There was 
great pain with distention of the abdomen, and death seemed inevitable, 

1 G-az. des Hopitaux, 1867. 

2 Amer. Journ. of Med. Sci. for July, 1867. 



SYMPTOMS. 775 

when, after the lapse of several days, a free evacuation occurred, and in 
the stool was a mass of worms firmly intertwined. 

Children often have lumbrici without any appreciable impairment of 
the general health, but their presence may intensify the symptoms of 
intercurrent diseases, and greatly increase the danger. Thus I recollect 
two children of three and three and a half years, with pneumonitis, who, 
at the same time, had lumbrici, one passing in the course of a few days 
thirty and the other twelve of these entozoa. Both presented well- 
marked physical signs of pneumonitis, and, though they recovered, the 
febrile movement and nervous symptoms were apparently aggravated by 
the intestinal affection. One had convulsions in the commencement of 
the inflammation, followed by profound stupor and amaurosis, lasting 
two or three days. 

Often the symptoms due to lumbrici coexist with those of a protracted 
and distinct intestinal disease. Thus, as we have seen, the intestinal 
secretions of typhoid fever and of chronic diarrhceal maladies afford a 
nidus for the growth of worms, and accordingly, at an advanced stage of 
these diseases, lumbrici are common. 

The symptoms produced by the oxyuris vermicularis are somewhat 
different. These worms do not usually cause the fever, disturbed diges- 
tion, the colicky pains, or the dangerous nervous symptoms which arise 
from the presence of lumbrici. Nor do they, like lumbrici, endanger 
life by crawling into unusual situations. In one recent case, I could 
detect no other cause of chorea than the presence of oxyurides, and 
eclampsia has been attributed to them, but such a result is exceptional, 
if, indeed, the cause be rightly assigned. 

Although the caecum is the chosen abode of this worm, and here more 
than elsewhere it exists in its normal state, it is not certain that it pro- 
duces any appreciable symptoms in this part of the intestinal tract. 

The symptoms which render this the most annoying of all the intes- 
tinal parasites are produced by these oxyurides, chiefly the females, 
which descend into the rectum, where by their active movements they 
produce intense itching. A small number of worms cause little incon- 
venience, but when many are present in the folds of the rectum their 
crawling produces such intense pruritus that the patient can with diffi- 
culty remain quiet. Usually this symptom is most marked in the early 
evening- when the child is warm in bed. It sometimes causes onanism 

CD 1 

in the girl as well as boy. This symptom may be nearly or quite absent 
during the day, but it returns so regularly at night as to resemble and 
be mistaken for a periodical nervous affection. So eminent a physician 
as Cruveilhier confesses that he has made this mistake of diagnosis. In 
the female child the oxyuris occasionally passes from the rectum to the 
vulva, producing leucorrhcea. 

In many instances tapeworms exist in children as well as adults, who 
thrive and present no symptoms, but in other instances there is more or 
less disturbance of the digestive function, with an uncomfortable sensa- 
tion in the abdomen. This sensation is more noticed after fasting, or 
after the use of certain kinds of food, and it is diminished by a full meal. 
Great hunger and a feeling of faintness are also common according 
to authorities, but I have not particularly remarked them in children. 



776 INTESTINAL WORMS. 

Irregular action of the bowels, vomiting, and various nervous symptoms, 
as itching of the nostrils, and anus, headache, tinnitus aurium, cardialgia, 
numbness, deafness, blindness, etc., have with more or less correctness 
been attributed to the tape-worm. Certainly such symptoms occasionally 
arise from this cause, for they cease with the expulsion of the worm. 1 
Intermittent colicky pains in the umbilical region were the only marked 
symptoms in a child with taenia whom I recently treated. Since the 
cysticercus cellulose is the embryonic form of the taenia solium, it is 
quite possible that individuals possessing the latter may be infected 
from its ova with the former, so that symptoms which have been attrib- 
uted to the intestinal parasite, have sometimes been due to the encysted 
embryo. We are unacquainted with the symptoms of the trichocephalus 
if any occur, and this worm is very rare in children. 

Diagnosis. — Bremser long since made the remark, and it has been 
repeated by most writers on diseases of children, that there is no sign or 
symptom which aifords positive proof of the presence of intestinal worms, 
except the expulsion of one or more. Late microscopic investigations 
have revealed, however, a pathognomonic sign, namely the presence of 
ova in the feces, which indicates not only the nature of the disease, but 
the species of the worm. 

The symptoms and disorders produced by lumbrici may all occur from 
other causes. Still, if several of them be present, and a careful examina- 
tion disclose no other cause, the presence of worms should be suspected, 
provided that the child be over the age of two years. The microscope 
may then be used for diagnosis. A little tentative treatment, entirely 
safe to the child, will also determine whether the suspicion be correct. 
One or two doses of medicine, administered under such circumstances, 
like the surgeon's exploring needle, may reveal the nature of the disease, 
and indicate the means of cure. 

In case of the oxyuris vermicularis, the itching directs attention to 
the anus as the place of the disease, and here the offending entozoa 
may often be discovered by the eye. 

Prognosis. — Intestinal worms produce a fatal result in only a small 
proportion of cases. Oxyurides never prove fatal, unless in rare in- 
stances, through convulsions. The manner in which death may be 
produced by lumbrici has already been pointed out. 

In general, when the nature of the disease is ascertained, the worms 
are readily expelled by treatment, and the patient restored to health. 
Therefore, if there be no complicating disease, the prognosis is good. 

Treatment. — Much injury has been done to children by the use of 
anthelmintics occasionally employed by physicians, but oftener by 
parents before the physician is called. Medicines of this kind are 
usually irritants, and, in many of those diseases which simulate the 
verminous affection, but are distinct from it, there is already an irri- 
tated if not an inflamed state of the intestinal mucous surface. 

Vermifuges administered under such circumstances obviously do 
harm, and in all acute diseases in which they are not required, even if 
their action be harmless, their employment is to be regretted, since it 

1 Medico-Chir. Rev., January, 1868. 



TREATMENT. 777 

consumes time which is very precious. It is thus that many lives are 
lost by the use of anthelmintic nostrums, which are extensively adver- 
tised and which command a ready sale, inasmuch as the belief in the 
presence of worms as a frequent cause of disease pervades all classes. 

A safe rule, followed by many physicians, and it would be much 
better if it were general, is not to give anthelmintics unless the child 
have passed one or more worms, or their ova be found in the feces, and 
not then if the symptoms seem to be referable to a coexisting disease. 
In doubtful cases in which the symptoms resemble those of worms, a 
purgative dose of calomel or calomel and rhubarb may be employed. 
It will generally bring away one or more lumbrici or a mass of ascaris 
vermicularis, if either species of entozoa be present. This purgative 
may be safely employed if there be no previous diarrhoea or debility. 
If after one or two doses and a free purgation no worms be passed, 
anthelmintic remedies should not be given, for it is almost certain that 
none exist. 

A large number of medicines have, or have had, a reputation as 
anthelmintics. Santonin, the active principle of the European worm- 
seed, is one of the best, and is much employed in this country and in 
Europe. It is nearly tasteless ; it may be given in powder, spread on 
bread with butter. It is kept in shops in one or two grain lozenges, 
with and without calomel. It has the advantage of easy administra- 
tion, and is destructive to both the round and thread worm. M. Bou- 
chut considers it preferable to all other remedies in the treatment of 
the round- worm. " To children two years of age he administers it in 
doses of ten centigrammes (1.54 grains), and in patients above this age 
the quantity is increased by five centigrammes (0.75 grain) for every 
additional year." He gives, in addition, occasional doses of calomel or 
castor oil. In this country santonin is usually administered in one to 
three-grain doses, two or three times daily, with an occasional purga- 
tive. The purgative is required to aid not only in the expulsion of the 
worm, but also of the ova. In overdoses santonin causes vomiting, 
diarrhoea, and altered vision, so that objects appear yellow, but in 
medicinal doses it produces no unpleasant consequences. Other medi- 
cines are preferable if there be symptoms of enteritis. For many years 
the anthelmintic most employed in this country was the pinkroot, the 
root of the Spigelia marilandica, an indigenous plant. It was not only 
prescribed by physicians, but employed by families as a domestic 
remedy. It is liable to cause, if the dose be large, cerebral symptoms, 
as vertigo, dimness of sight, spasm of the facial muscles, stupor, and 
even convulsions. These effects less frequently occur if the pinkroot 
be given with a purgative, and it has been customary to administer it 
in combination with senna in an infusion. A half ounce of spigelia 
with an equal quantity of senna is macerated for two hours in a pint of 
boiling water, and then strained. For a child two or three years old 
the dose is half an ounce to one ounce. So popular has this Vermi- 
fuge been in this country, that probably a majority of the native-born 
adults in the States recollect the nauseating doses of pinkroot adminis- 
tered by anxious parents. Pharmacy now provides us with the same 



778 INTESTINAL WORMS. 

medicine in a more convenient and acceptable form, that of the fluid 
extracts : 

R. — Fluid ext. spigel. f?j. 

Fluid ext. sennse fgss. — Misce. 

One teaspoonful to a child from three to five years. 

The officinal fluid extract of spigelia and senna may be given in the 
same dose. Professor Procter recommends the addition of santonin to 
this extract : 

R. — Fluid ext. spigel. et sennae ..... f|jj. 

Santonin gr. viij. — Misce. 

This is probably the best anthelmintic that can be employed for the 
destruction of the round-worm in uncomplicated cases, and it is also 
very useful in treating the ascaris vermicularis. Chenopodium is also 
a good anthelmintic. It is efficient, and at the same time one of the 
safest in case the mucous membrane be inflamed. If there be abdominal 
tenderness, with stools too frequent, and thin, or mucous, and tinged 
with blood, I should prefer the chenopodium to most of the other ver- 
mifuges. To a child of three years five drops of the oil may be given 
three times daily. It may be continued for a longer period than would 
be safe for most of the other vermifuges. Twice a week, during its use, 
a mild purgative should be given, as castor oil, rhubarb, or magnesia, 
unless the bowels are open. It may be given dropped on sugar, or in a 
mucilaginous mixture. 

Dr. J. F. Meigs says : "I myself rarely give any other remedy than 
wormseed oil in slight and especially in doubtful cases, unless this has 
already been tried and failed. From my own experience, I believe that 
this remedy is all-sufficient in a large majority of the cases that occur 
in this city, as these are almost always of a mild character, and as it 
not only produces the expulsion of the parasites when they exist, but 
also acts beneficially upon the forms of digestive irritation which simu- 
late so closely the symptoms produced by worms. I am persuaded, 
indeed, that of all the cases that have come under my notice, in which 
it seemed probable that worms might be present, none were expelled in 
nearly half, and yet the signs of disturbed health have passed away 
under the use of the remedy." .... "The following is a very 
good formula for the administration of this remedy : 

R. — 01. chenopodii gtt. lx vel f gj. 

P. g. acacise . . . . . . . . zij. 

Syrup, simplic 3J. 

Aq. cinnamom 3 ij- — Misce. 

" Give a dessertspoonful three times a day for three days, and repeat after several 
days." 

In cases of protracted intestinal disease attended by an increased and 
vitiated secretion from the mucous surface, a state which often gives 
rise to worms, turpentine is one of the best anthelmintics. In fact, in 
some of these cases there is no good substitute for it. For example, a 
boy of about ten years, attended by myself, October, 1864, had reached 
or nearly reached the fourth week of typhoid fever, when he passed 



TREATMENT. 



779 



from his bowels a large quantity of blood. He was previously emaci- 
ated and weak, and there had been, as is usual in such cases, consider- 
able diarrhoea. The hemorrhage was attended with great prostration, 
from which, however, he partially rallied by the use of stimulants. On 
the following day an equally severe hemorrhage occurred, attended 
with coldness of the face and extremities and great feebleness of pulse, 
so that death appeared imminent. Turpentine was now administered 
every six hours, a few lumbnci were passed, and the case thenceforth 
progressed favorably. The mechanical effect of the lumbrici on the 
ulcerated surface of intestine had probably given rise to the hemor- 
rhage. Turpentine may be given in doses of from five to ten minims 
three times daily to a child five years old. Sweetened milk or sugar in 
powder is a good vehicle for it, or it may be given in a mucilaginous 
mixture. 

R. — Spts. terebinth, rect gij. 

01. limonis ........ gtt. v. 

Mucil. gum aeac, 

Syr. simplic. . . . . . . . . aa gvj. 

Aq. anisi . . . . . . . . ^j-ij.- 

Dose, one teaspoonful every six hours. 



■Misce. 



The following formula for the employment of this agent is recom- 



mended by Dr. Condie : 

R • — Mucil. gum acac. 
Sacch. alb. 
Spir. aether, nitr. 
Spir. terebinth, rect. 
Magnes. calcinat. 
Aquae menthae 



3x. 

^j. — Misce. 



It is useless to enumerate the many anthelmintic mixtures which 
have been extolled from time to time. Those mentioned above are the 
least nauseous, and will rarely disappoint the practitioner. One other 
antidote for the round-worm should be mentioned, as it has been much 
used and is efficient, namely, cowhage. This consists of the bristles 
which cover the pods of the Mucuna pruriens, a tropical plant. The 
pods are dipped in plain syrup of the ordinary consistence, and the 
bristles are scraped off with the syrup. When enough of the medicine 
is added to render the syrup of the consistence of thick honey, it is 
ready for use. The dose is a teaspoonful every morning for three 
days, after which a cathartic should be administered. I have never 
prescribed cowhage, although it is not unfrequently ordered by phy- 
sicians, and a popular nostrum consists chiefly of it. 

One affected with tapeworm is obviously cured only when the head of 
the parasite is expelled ; but, in the majority of cases which I have ob- 
served, the head has not been found in the evacuations, even when the 
treatment had effected a complete cure, as shown by the subsequent 
history. The chain of expelled segments commonly terminated very 
near the head. This I believe is the common experience if we trust the 
friends of the patient with the examination of the stools. The physi- 
cian himself should search for the worm's head, the evacuations being 



780 INTESTINAL WORMS. 

preserved. The nurse should be directed to add a little carbolic or 
salicylic acid, and a sufficient quantity of water nearly to fill the vessel. 
The liquid should not be roughly stirred with a stick, as physicians are 
in the habit of doing, since this breaks the worm into small portions, 
and renders the inspection more difficult, but it should be shaken fre- 
quently so as to detach the segments and head, if it be present, from 
the fecal matter. After it has stood at least five to ten minutes, the 
worm, which has greater specific gravity than water, sinks to the bot- 
tom, and the upper part should be poured off. This process must be 
repeated till the water is nearly colorless, after which search should be 
made for the fragments, and the head, if present, will be found. 

Since entire expulsion of the tape-worm is effected with difficulty, 
preparatory treatment for about forty-eight hours should be employed 
before the vermifuge is administered. During this time the patient 
should take a mild purgative once or twice, and such food, in moderate 
quantity, should be allowed as leaves little residuum, as beef-tea, milk, 
etc., with some stimulant, if the patient feel exhausted. There are 
three articles of food which experience has shown to be especially useful 
in this preparatory treatment, perhaps from a sickening effect which 
they produce upon the worm, namely, salt herrings, onions, and garlic. 
They may, therefore, be taken as food in the twelve or eighteen hours 
preceding the employment of the vermifuge, which it is ordinarily most 
convenient to administer in the morning. 

The various tsenicides recommended in the books are probably all 
more or less efficient, but the one which has given most satisfaction in 
the Outdoor Department at Bellevue, where probably a larger number 
of these cases are treated than in any other place in this country, is the 
oil of male fern ; but it is found necessary to employ a larger dose than 
is recommended in some of the books. For a child of six years the 
dose employed is one drachm in any convenient vehicle, as the syrupus 
aurantii florum. This should be followed in about four hours by a dose 
of castor oil, which completes the treatment. Heller, a high German 
authority, recommends koosso or its active principle koossin, in the use 
of which I have had no personal experience. The pumpkin-seed has 
also been employed at Bellevue and in other parts of this city, but it 
seems to be less efficient than the oil of the fern. If the chain of seg- 
ments break near the head, and the head be not seen, it will be necessary 
to wait two or three months, in order to determine whether the cure is 
complete. 

Since the symptoms produced by the oxyuris vermicularis are refer- 
able chiefly to the rectum, and are caused by the active movements of 
the worm, the prompt and thorough use of enemata, which causes their 
expulsion, is evidently required. Enemata are more effectual if used 
cool than if warm; and since this worm inhabits the csecum as well as 
rectum, large enemata given through a long tube or a large catheter 
are more effectual, causing the expulsion of a larger number of worms 
than are expelled by small enemata employed in the usual manner. 
Various substances have been used for this purpose, as lime-water, table 
salt in water, turpentine in milk, decoction of aloe, decoction of garlic, 
etc. Heller says : " Simple water would do well for this purpose, for 



GASTRO-INTESTINAL HEMORRHAGE. 781 

in a short time it causes the worm to swell up and burst ; but that is 
not altogether without an injurious effect on the intestinal mucous 
membrane. Hence, Vix recommends a solution of castile soap, in dis- 
tilled water, or rain-water, of the strength of one to two and a half 
grains to the ounce. This has no unpleasant action on the intestinal 
mucous membrane, while at the same time it quickly destroys both the 

worms and their eggs Yix has tested all the medicines 

usually used in enemata, and has found the above solution of castile 
soap to be the most effectual." The use of the enema in the evening, 
although only a small quantity of liquid be used, so as to wash out the 
rectum, insures relief from the itching and sleeplessness during the 
night. 

But it is undeniable that enemata alone do not effect a complete and 
permanent cure in a large proportion of cases, and hence those affected 
with this worm remain sufferers for years, having only a temporary 
respite, unless medicines be administered by the mouth. Those medi- 
cines which produce free watery evacuations appear to be the most 
effectual in dislodging and expelling oxyurides, whose attachment to the 
intestinal surface is not strong ; therefore Heller recommends the saline 
purgatives "joined with copious draughts of water." 



CHAPTER XII. 

GASTROINTESTINAL HEMORRHAGE. 

Hemorrhage from the capillaries is more frequent in infancy than 
at any other period of life, whether in consequence of the irregularity 
of the circulation and frequent congestions in the infant, or the greater 
delicacy and feebleness of the minute vessels at this age. Hemor- 
rhage, generally capillary, from the gastro-intestinal mucous surface, 
occurs sufficiently often in the child, and especially in the infant, to 
render it a disease of some importance. It is more frequent the 
younger the individual. 

This hemorrhage occurs in three distinct pathological stages : first, 
in the newborn infant from causes not fully ascertained; secondly, 
from a pathological state of the blood or the vessels in which it circu- 
lates, and which is often connected with purpura hemorrhagica ; 
thirdly, from a local cause. 

First Variety. — In 49 cases, which I have collected from different 
writers, the hemorrhage occurred in 38 under the age of six days, in 5 
from six to ten days, and in 6 from ten to twenty days. Some authors 
cite cases which occurred at the age of several weeks, but hemorrhage 
into the intestines at so late a period cannot be due to any cause oper- 



782 GASTROINTESTINAL HEMORRHAGE. 

ating at birth, and it is proper to consider such as examples of one of 
the other varieties. 

Passive congestion of the gastro-intestinal mucous membrane is not 
infrequent in the newborn. Billard speaks of twenty-five cases with- 
out hemorrhage which he has examined. This anatomical state of the 
mucous membrane of the intestines, whether occurring as a part of a 
general plethora or being simply a local affection with no hyperemia 
of other parts, evidently requires only a certain increase and hemor- 
rhage results. 

The cause of the abnormal congestion of the gastro-intestinal mucous 
membrane, so common in the newborn, has been referred by writers to 
the previous health of the parents, to circumstances attending the birth, 
especially to too speedy a ligature of the cord, to irritant matters in the 
intestines, to external violence, and to the two opposite extremes, 
namely, a plethoric and a feeble state. In my opinion, the chief cause, 
in many cases, is the tardy or incomplete establishment of the respira- 
tory and circulatory functions, which gives rise to congestion in the 
cavities of the heart and in the lungs, and, consequently, in the capil- 
laries throughout the system. Evidently, this congestion is most in- 
tense in the full-blooded. Billard says of fifteen cases of intestinal 
hemorrhage which he examined, most of them were remarkable for the 
plethoric condition of their bodies and the general congestion of their 
integuments. Some, on the contrary, were pale and feeble, as is com- 
mon after abundant hemorrhage. 

In two infants who died soon after birth, and whose bodies I subse- 
quently examined, there was apparently a plethoric state, which ren- 
dered a fatal result more certain, if it did not, indeed, produce it. In 
one of these, in addition to intense general congestion, meningeal apo- 
plexy had occurred, although the birth of the child had been easy. 

It is not difficult to understand in what way too speedy a ligature of 
the cord may be a cause of capillary congestion and hemorrhage. At 
the moment of birth, the uterus is contracted, the placenta compressed, 
and, if the cord be now tied, more blood remains in the vessels of the 
infant than if tied a little 'later. A little later, in consequence of the 
temporary cessation of uterine contractions, and the reestablishment of 
circulation in the infant, blood flows .through the cord toward the pla- 
centa. The cord thus acts as a safety-valve to Ihe circulation. Any 
accoucheur who will take pains to witness the effect on the cord of the 
return of circulation, will observe what I have stated. Too speedy a 
ligature of the cord would not, however, be sufficient in the majority of 
cases to produce that amount of plethora which gives rise to intestinal 
hemorrhage without other cooperating causes. 

Tardy or incomplete establishment of respiration and circulation, 
which gives rise to intestinal congestion and hemorrhage, may be due 
to disease of the heart or lungs, as atelectasis or cyanosis, to feebleness 
of the infant, or to slow and difficult birth. In a large proportion of 
cases, however, the birth is easy. Thus, three of five patients with 
intestinal hemorrhage, who were treated by M. Gendrin, were born of 
an easy labor, and the same was true of four infants observed by M. 
Kiwisch. 



©ASTRO-INTESTINAL HEMORRHAGE. 783 

Although gastrointestinal hemorrhage in the newborn apparently 
results in certain instances from the conditions mentioned above, which 
produce congestion of the gastro-intestinal mucous surface, there are 
other cases in which the cause must be different. Dr. Silverman. 1 of 
Breslau, has recently published the statistics of 42 cases, 23 of which 
were fatal. In 25 of these the blood escaped both from the mouth and 
anus, in 10 from the anus alone, and in 7 from the mouth alone. The 
hemorrhage, in a majority of the cases, began on the second day after 
birth, but in 11 it began on the first day, and in all prior to the eighth. 
It is suggested that the hemorrhage, in certain instances at least, occurs 
from an ulcer in the gastro-intestinal surface, which is produced by an 
embolus in the umbilical vein, or its branches, or by suspension or 
incomplete establishment of the respiratory function in consequence of 
accidents of birth, atelectasis, etc. Ebstein, according to Silverman, 
has demonstrated experimentally that the suspension of respiration in 
animals produces congestion, extravasation of blood, ulceration in the 
stomach. From the foetal anatomy, it is evident that an embolus oc- 
curring in the umbilical vein near the liver, and extending into the 
branches of the vein, would be likely to cause congestion of the intes- 
tines by obstructing the portal circulation. 

Dr. Lederer 2 states that he has treated eight newborn infants for this 
disease, five of which died from the severe gastric and intestinal hem- 
orrhage, accompanied also by umbilical hemorrhage. The age of the 
youngest was six hours. That of the oldest eleven days. They were 
all well developed, of normal conformation, and were nourished with 
breast-milk. In the three who were cured, the hemorrhage was 
arrested in twenty-four hours, but there was for a long time a tendency 
to intestinal catarrh. Dr. Lederer admits the obscurity of the cause, 
but does not think that it was an embolism in all the cases. 

The second variety of gastro-intestinal hemorrhage often occurs as a 
•sequel of other and debilitating diseases. I have known it to occur as 
a sequel of measles, smallpox, scarlet fever, and in one case of typhoid 
fever. One of these patients, when apparently the period of danger 
was passed, began to lose blood from nearly all the mucous surfaces, 
from the nostrils and gums, as well as intestines, and the case, which 
but for the hemorrhage would doubtless have had a favorable issue, 
terminated fatally in less than a week. 

Patients with this variety of gastro-intestinal hemorrhage sometimes 
present the maculae of purpura, and commonly their aspect is pallid and 
cachectic. The following was a fatal case of hemorrhage occurring 
from the ileum, in a mild form of purpura hemorrhagica. 

Case. — An infant, eight months old, of healthy parentage, nursing, with 
no previous sickness, and fleshy, vomited a small quantity of blood on the 
'25th of March, 1865 ; soon after it passed a stool consisting of almost pure 
blood. On the following day five or six patches of purpura hasruorrhagica 
were observed on the arms and legs. These macular continued till death. 
There was no more hsematemesis, but the stools, which were from two to 

1 Jahr. fur Kinderh., Sept. 1877. 2 Zeitung fur Kinderh., Nov. 1877. 



784 G ASTRO-INTESTINAL HEMORRHAGE. 

four daily, consisted largely of blood. Death occurred from exhaustion 
on March 31st. 

Sectio Cadaver. — Head not examined ; thoracic organs healthy, but 
pale ; liver fatty ; stomach, upper part of small intestines, and entire colon 
of normal appearance, unless presenting a somewhat lighter color than 
the healthy intestine from deficiency of blood ; mucous membrane in the 
ileum, to the extent of several inches, intensely injected without thicken- 
ing. The blood had obviously escaped from this portion of the intestine, 
and a moderate amount of this fluid was found in the tube below the 
point of vascularity. This case is interesting not only on account of the 
development of purpura hemorrhagica, but because of the subsequent 
intestinal hemorrhage in a nursing child, apparently of healthy parent- 
age, and without previous sickness. 

In our remarks on internal convulsions, the case is related of a 
scrofulous infant, who, to all appearance in her ordinary health, sud- 
denly became affected with intestinal hemorrhage in connection with 
external and internal convulsions. A point of interest in this case was 
the relation of the hemorrhage to the neurosis. In one of the three 
cases of intestinal hemorrhage described by West, there were also con- 
vulsions. In rare instances there is an hereditary hemorrhagic diathesis 
to which the hemorrhage is attributable. The late Prof. Swett 1 relates 
the history of a hemorrhagic family. Seventeen out of eighteen chil- 
dren of this family had died of hemorrhages, and the survivor had had 
intestinal hemorrhage with epistaxis. 

In the third variety, among the local causes producing hemorrhage 
may be mentioned ulceration, as in typhoid fever, or in severe intestinal 
inflammation, the mechanical effect of solid substances, lumbrici, invagi- 
nation, obstruction to the portal circulation, polypus of the rectum. 
Occasionally at the post-mortem examination of young infants I have 
found blood with mucus in the duodenum and jejunum, these portions 
of the intestines being at the same time intensely congested. In one. 
case of protracted entero-colitis occurring in the summer season, I 
found many small circular ulcers in the colon, nearly all containing 
points of extravasated blood. Such are the principal local causes of 
hemorrhage from the bowels. Ordinary colitis may also be considered 
a cause, although the amount of blood evacuated in this disease is com- 
monly small. 

Of the three forms of intestinal hemorrhage described above, that 
arising from local causes is most frequent, while that occurring from a 
purpuric or hemorrhagic diathesis is least frequent. In rare cases fatal 
intestinal hemorrhage may occur in the newborn, and the blood be 
retained in the intestine, or if passed it may so closely resemble the 
meconium that its true nature is not discovered. Mr. Bednar 2 relates 
the following case: "On the eleventh day after birth the boy's skin 
(then of a pale yellow color) diminished in. warmth, the impulse of the 
heart became dull and prolonged, the respiratory murmur scarcely per- 
ceptible. The child lay almost motionless and slumbering. The day 

1 New York Journal of Medicine and Surgery, July, 1840. 

2 Krankheiten der Neugeboriien. 



TREATMENT. 785 

following the surface could scarcely be kept warm, and the little patient 
had to be aroused to suck. On the twentieth day after birth it died. 
The brain was found to be anaemic, the lungs plethoric, while the blood 
was effused into the duodenum and stomach." 

Intestinal is more frequent than gastric hemorrhage, and the flow, 
except when produced by a local cause, is usually from the small intes- 
tines. The blood, unless it come from a point near the anus, as the 
rectum or descending colon, is commonly dark, and sometimes partially 
decomposed, emitting an offensive odor. Admixture of the blood with 
the intestinal secretions prevents coagulation of the fibrin. 

Gastro-intestinal hemorrhage in itself produces few symptoms aside 
from the prostration which attends all hemorrhages. The disease with 
which it is associated may give rise to many and severe symptoms. 

Prognosis. — The result in the first and second varieties is much 
more unfavorable than in the third. Many newborn infants affected 
with gastro-intestinal hemorrhage die, but some recover. Billard 
attended fifteen fatal cases. It is probable, however, that death in the 
first variety is often due more to some coexisting lesion, than to the intes- 
tinal hemorrhage. Meningeal apoplexy, and the incomplete establish- 
ment of the circulatory and respiratory functions, may both operate as 
direct causes of death in this variety. 

In the second variety, also, a very guarded prognosis should be 
given ; so great a change in the circulatory system as to cause rupture 
of the capillaries, or transudation of blood in the ordinary course of the 
circulation, is a serious state. When this hemorrhage occurs as a sequel 
of the eruptive fevers, or in purpura hemorrhagica, the patient is more 
likely to die than recover. 

In the third form of intestinal hemorrhage, the result depends on the 
nature of the cause, whether it be susceptible of removal. The majority 
of cases in this variety recover. 

Treatment. — Billard recommends, as a means of preventing capil- 
lary congestion and hemorrhage in the newborn, to allow a little blood 
to escape from the umbilical cord before its ligation, if the establish- 
ment of respiration and circulation be difficult or incomplete. This 
relieves the hyperemia of the internal organs and facilitates the flow 
of blood. After the commencement of internal hemorrhage and the ap- 
pearance of bloody stools, the same may be done if plethora be indicated 
by the florid and robust appearance of the infant, and the cord be not 
too much shrivelled. 

The treatment both therapeutic and regimenal, of intestinal hemor- 
rhage, should vary according to the age and state of the infant, the pro- 
fuseness of the hemorrhage, and the nature of the cause. Perfect 
quietude, in the recumbent position, is requisite in all severe cases. 
Derivation to the extremities should be procured in the young infant, 
by heated dry flannel or flannel wrung out of hot water ; in the older 
infant, by the same with the addition of mustard. The nursing infant 
should remain at the breast, being allowed, perhaps, in addition to the 
breast-milk, a little cool barley or gum-water. Spoon-fed infants should 
be given food of the blandest quality, in the liquid form and cool. This 
is the proper diet, whatever the age, in the commencement of the hemor- 

50 



786 GASTRO- INTESTINAL HEMORRHAGE. 

rhage. If there be evidence of exhaustion, cool beef-tea, or essence, 
and alcoholic stimulants, are necessary. It has been advised, in certain 
forms of intestinal hemorrhage, to apply leeches over the abdomen or 
around the anus. This treatment would, in my opinion, rarely be 
useful, but, on the contrary, in most cases, injurious. Hemorrhage 
from a mucous surface, which, when once established, generally quickly 
relieves the local hyperemia, and leeching will, unless very cautiously 
employed, promote the prostration, in which the real danger in this 
disease consists. On the other hand, moderate counter-irritation over 
the abdomen may be attended with real benefit as a derivative. 

The therapeutic treatment consists mainly in the use of astringents. 
Of the mineral astringents, acetate of lead and nitrate of silver have 
been used, but the liquor ferri subsulphatis is preferable to all other 
astringents in hemorrhage from the stomach and upper part of the small 
intestine, but it is believed to be decomposed in its passage through the 
intestine, so that it has less astringent or styptic effect in the lower bowel 
than gallic acid. It may be given to a child five years of age, in doses 
of five drops, in sweetened water or in mucilage. 

Astringent enemata are sometimes useful. M. Rilliet treated a case 
which recovered with enemata, each containing twelve grains of extract 
of rhatany, a strong decoction of the same astringent being applied ex- 
ternally to the abdomen. M. Bouchut recommends " cold water exter- 
nally to the abdomen, internally by the mouth, or by enemata frequently 
repeated. These enemata should be composed of two or three large 
spoonfuls only. They may be rendered more active with three grains 
of tannin, or with seven grains of the extract of rhatany or seven grains 
of catechu, or, lastly, with one grain of nitrate of silver. In this latter 
case, a small glass syringe and distilled water must be used, to avoid the 
premature decomposition of the medicine." 

In the hemorrhage occurring in purpura, or after exhausting consti- 
tutional diseases, tonics should be given in addition to astringents. In 
chronic inflammatory disease of the intestinal mucous membrane, at- 
tended by a vitiated secretion of the follicles, the hemorrhage may be 
best treated by turpentine. I have elsewhere related two cases of recovery 
by the use of this agent, in one of which (typhoid fever) lumbrici were 
expelled. Ergot, from the contracting influence which it exerts on the 
arterioles, is also useful in many cases. It is especially useful in purpura 
haemorrhagica. 

If the hemorrhage be due to a local cause, as lumbrici or a rectal poly- 
pus, the treatment obviously should consist in the removal of this cause. 



INTUSSUSCEPTION. 787 



CHAPTEE XIII. 

INTUSSUSCEPTION. 

Intussusception, or the passage of one portion of intestine into 
another, has long been known as an occasional accident. Hippocrates, 
though debarred from the study of morbid anatomy, appears to have had 
a pretty clear idea of this lesion, and he suggested a mode of treatment 
which has been employed till the present time. 

Intussusception without Symptoms. 

This is not properly a disease. It consists in a displacement without 
any other anatomical change. There is, therefore, no obstruction, in- 
flammation, or even congestion present, and no symptoms. This form 
of invagination might ordinarily be reduced by the normal peristaltic and 
vermicular movements of the intestine. 

Invagination of a portion of the small intestine into the part imme- 
diately below it is often observed at the post-mortem examination of 
young infants, who had presented no symptoms due to the displacement. 
The invaginated mass is usually from half an inch to two inches in 
length, and, as a rule, this accident is multiple. There may be ten or 
more distinct intussusceptions, at distances of a few inches from each 
other. The simple displacement is believed to occur ordinarily at or a 
short time prior to the moment of dissolution. It has been supposed to 
be most frequent in those who have died of cerebral or spasmodic dis- 
eases, but its occurrence is not unusual in other pathological states. I 
have often found it at the post-mortem examination of infants who have 
had subacute or chronic entero-colitis. Heven states that he has seen it 
at the Salpetriere more than three hundred times. Billard has seen it 
especially in infants who have been subject to constipation. Any irri- 
tant, mechanical or other, which disturbs the regular movements of the 
intestines, doubtless may produce it. It has been caused in the rabbit 
by irritating the anus. 

It is not improbable that simple intussusception occasionally occurs 
temporarily in children whose health remains good, when the regular 
movements of their intestines are disturbed by irritating ingesta or other 
causes. This form of displacement never takes place in the large intes- 
tine. It usual seat is the lower part of the jejunum, and upper part of 
the ileum. Since it possesses little interest as regards pathology, and 
none whatever as regards symptomatology and therapeutics, it may be 
ignored in our description of intussusception. 



INTUSSUSCEPTION. 



Intussusception -with Symptoms. 

Intussusception, or invagination, is one of the most painful and dan- 
gerous of human maladies, but fortunately is not very frequent. I have 
the records of fifty-two cases occurring in children, from which the facts 
contained in this article are chiefly derived. The patients were under 
the age of twelve years. 

Previous Health. — In thirty-four of the fifty-two cases, the state 
of the health previously to the invagination was recorded. From the 
following table it is seen that half, or seventeen, were previously well, the 
remaining half suffering from some disease or derangement : 

Previous Health. 



Age. Good. Disease or Derangement. 

One year or under ...... 15 8 

Over one year 2 9 

17 17 

MM. Rilliet and Barthez, whose views in reference to intussusception 
are derived from the examination of the records of twenty-five cases, 
state that the previous health is ordinarily good, and the intussusception 
is, therefore, primary. Their remark, according to the above statistics, 
is seen to be correct as regards patients under the age of one year, but 
incorrect for those over that age. 

Most of the seventeen who had previous ill-health had diarrhoea, 
dysentery, or constipation, or diarrhoea alternating with constipation. 
Of those otherwise affected, one had thread-worms, two obscure ab- 
dominal pains, one nausea and vomiting, and one, whose age was four 
months, had had symptoms of invagination when ten weeks old, which 
soon passed off. It is seen that the preexisting affections were ordi- 
narily such as would be likely to accelerate the movements of the intes- 
tines and at the same time render them irregular. 

Causes. — The above statistics, therefore, show that intussusception is 
often preceded by disease or functional derangement of the intestines. 
The two opposite conditions, namely, constipation and the diarrhoea! 
maladies, so often precede the displacement that they must be regarded 
as common causes. Another probable cause is intestinal worms, which, 
by their mechanical action, stimulate the intestines. They were present 
in three of the fifty-two patients, though two of the three seemed well 
till the occurrence of the intussusception, but the other patient had 
complained of irritation at the anus, and ascarides had been found on 
examination. 

The use of irritating and indigestible food is an occasional cause. 
Thus, some who have had intussusception have been in the habit of taking 
fruits, candies, and pastries freely. Such ingesta may be an immediate 
cause by their irritating effect, or a remote cause giving rise to diar- 
rhoea, which, in turn, produces intussusception. 

Sex is a predisposing cause, since male patients are largely in excess. 
Of the twenty-five cases collated by Rilliet and Barthez, all but three 



AGE. 789 

were boys. In our own collection, the sex of thirty-four of the patients 
was recorded, and of these twenty-three w^ere boys. 

In rare instances external violence is the apparent exciting cause. 
One patient received a severe contusion of the abdomen two years before 
death, and from this time continued to complain at intervals of pain in 
the bowels. One writer also mentions the case of a child nine years old, 
who received a blow from a comrade at school, and from this time had 
alternately diarrhoea and constipation till the invagination commenced. 
Rilliet and Barthez also relate the cases of two children who were taken 
suddenly with invagination when their parents were tossing them in 
their arms. 

Age. — Of the fifty-two cases embraced in our statistics, the ages were 
as follows : 



3 were 3 months 


old. 


1 was 10 months old. 


12 " 4 


a 


tt 


1 " 11 « 


3 " 5 


« 


n 


1 « 12 " " 


5 " 6 


ti 


u 


2 were from 1 to 2 years old 


1 was 7 


« 


a 


8 " " 2 « 5 " " « 


1 ' 8 


tt 


tt 


8 " "5 " 12 " " 


3 were 9 


a 


a 


3 not given. 



Therefore, no cases occurred under the age of three months, 23 cases 
were between the ages of three and six months, or nearly one-half of the 
entire number, 8 between the ages of six months and one year, and 
only 18 between the ages of one year and twelve. These statistics 
correspond, in the main, with those of Rilliet and Barthez, in whose 
collection of twenty -five cases no one was under the age of four months. 
Leichtenstern 1 says : "Half of all invaginations, according to my statis- 
tics of four hundred and seventy-three cases, occur during the first ten 
years. The first year after the third month is remarkable for a special 
frequency — one-fourth of all intussusceptions." 

The great liability to intussusception in infancy is due partly to the 
anatomical character of the intestine in this period of life, and partly, 
doubtless, to the fact that there are more frequent irregularities in the 
intestinal movements than in older children. In the infant the walls 
of the intestines are thin, the mucous and muscular coats and the con- 
nective tissue being much less developed than in those that are older; 
the mesentery and meso-colon have also greater depth as compared 
with the same in other periods of life, except the meso-colon at the 
points where it passes over the kidneys, in which places it is very short, 
or even in some cases nearly absent. Moreover, the space occupied by 
the large intestine, in which part of the digestive tube intussusception 
commonly occurs, is much shorter relatively to the length of the intes- 
tine than in those that are older. In about thirty measurements which 
I have made of the length of the large intestine and the space occupied 
by it, the latter was found, on the average, about one-third that of the 
former, which, of course, necessitates doubling of the intestine on itself. 
These peculiarities of structure in the infant obviously favor the occur- 
rence of intussusception. 

1 Ziemssen's Encyclop. 



790 INTUSSUSCEPTION. 

Seat and Pathological Anatomy. — While intussusception occur- 
ring without symptoms is usually multiple, that form which occurs with 
symptoms is ordinarily single. Two exceptional cases which I observed 
will be presently related. In one of the cases embraced in the statistics 
an invagination occurred with symptoms, and coexisting with it was 
another in the small intestines apparently without symptoms, and quickly 
reduced by handling. 

While intussusception without symptoms occurs in the small intes- 
tine, the seat of intussusception with symptoms is, with occasional ex- 
ceptions, the colon. The colon constitutes the entire invaginated mass, 
or else, and more frequently, it forms the exterior, w T hile the incarce- 
rated portion consists wholly or in part of the ileum. 



Intussusception in the Small Intestines. 

Bouchut says : " M. Rilliet states, in a recent treatise, that in infancy 
the intestinal invagination is always accomplished at the expense of the 
large intestine, and that there is never invagination of the small intes- 
tine. This is incorrect. I have observed the small intestine invagi- 
nated in the adjacent inferior part. Taylor has reported a case of this 
kind in a child twenty months old, who died after an attack of acute 
peritonitis. M. Marage has seen another case in a child thirteen 
months old, who recovered after having voided the invaginated portion 
furnished with two of those diverticula so frequent in the small intestine 
of the foetus." 

But, from all that appears, the case reported by M. Marage may have 
been, and probably was, an example of the common form of intussus- 
ception, namely, of the ileum into the colon. In Mr. Taylor's case the 
invagination was really of the ileum into the colon, although a small 
portion of the ileum next to the valve had not been inverted, so that it 
constituted a little of the exterior of the mass. 

Nevertheless, Bouchut is correct in stating that irreducible and fatal 
intussusception may occur in the small intestines. Probably the dis- 
placement is at first of the simple variety, but, continuing and increas- 
ing in extent, its return becomes impossible. The positive statement 
of so great an authority as M. Rilliet, that intussusception with symp- 
toms does not occur in the small intestines, justifies the publication of 
the following cases, which establish the fact that there are instances, 
though not frequent, in which the displacement does have this location : 

Case I. — Male. This patient's health had been uniformly good, and 
nothing unusual was observed in his condition till the age of four and a 
half mouths, when he became restless, as if in almost constant pain, with 
occasional exacerbations. Castor oil was prescribed, which operated freely, 
and then the following mixture : 

R. — Magnes. calcinat 9J. 

Tinct. opii camphorat 5 ij ■ 

Tinct. asafcet. . Jps- 

Aq. anisi §j.— Misce. 

Dose, ten to twenty drops, repeated according to the pain. 



INTUSSUSCEPTION" IN SMALL INTESTINES. 



791 



These remedies failed to give relief, as did also chloroform given in 
doses of two drops. After two or three days, anothor set of symptoms 
arose, those characteristic of pneumonitis, to wit, hurried respiration, 
accelerated pulse, short suppressed cough, and expiratory moan. He was 
treated with the oiled silk jacket, and mild counter-irritation, and took 
an expectorant mixture containing ammonium carbouate. In a few days 
the pulmonary disease was evidently subsiding, but the pain in the abdo- 
men, with occasional exacerbations, continued. His countenance was 
pallid, and bore an expression of suffering. There was no distention or 
tenderness of abdomen, and no abdominal tumor. He took little nutri- 
ment, and seldom vomited. In the last part of his sickness the dejections 
were scanty, and the last three days his stools consisted mainly of mucus 
and a little blood. The pain seemed to be growing less, when he was 
seized with convulsions, and died the same day, precisely two weeks from 
the commencement of his sickness. 

Sectio Cadaver. — Head not examined ; body slightly emaciated ; mu- 
cous membrane of trachea and bronchial tubes vascular ; posterior por- 
tion of the lower lobe of each lung solid, of greater specific gravity than 
water, and allowing only partial inflation ; it was in the second stage of 
pneumonitis. Stomach, duodenum, jejunum, healthy. In the upper part 
of the ileum was an intussusception two-thirds of an inch long, presenting 
no trace of inflammation, either within or around it, and its vascularity, 
when it was examined externally, did not seem notably increased. Above 




the intussusception the intestine was empty ; below it, and chiefly in the 
small intestine, was a dark-colored substance evidently blood, and giving 
in a few hours the offensive odor of decaying animal matter. There was 
a passage through the intussusception, at least two or three lines in diam- 
eter, as shown by a probe. The intussusception sustained the weight of 
sixteen inches of the intestine, and it would apparently have sustained con- 
siderably more. The remaining organs were healthy. 

Case II. — F. S., a female infant, four months old, was treated at the 
New York Infant Asylum in June and July, 1865, for entero-colitis, the 



792 INTUSSUSCEPTION. 

usual epidemic of the summer season. The following records show the 
state of the bowels immediately before her death : 

June 29th. Has five or six stools daily. 30th. Two stools in twenty- 
four hours. July 1st. Had two stools siuce the last record ; no vomitines 
3d. Four stools in last twenty-four hours. 4th. The diarrhoea continug. 
as before ; the stools about four daily. On the 6th of July she died. 

Her pulse during the time in which these records were taken generally 
numbered about 128 per minute. She was much emaciated, and the day 
before death she frequently struck her head with her hand. The medi- 
cines employed were mainly alkalies and astringents. 

Sectio Cadaver. — Parietal bones united ; serous effusion over the con- 
volutions of the brain, under the arachnoid; occipital bone depressed; 
commencing at a point about two feet below the stomach were four intus- 
susceptions two or three inches from each other. The invaginated masses 
were from one to one and a half inches in length, and three of them were 
found to be very vascular in their interior. Above, between, and imme- 
diately below the intussusceptions the intestine was healthy. One of the 
invaginations was tested by weight, and was found to sustain a foot and 
a half of intestine, and would have sustained more. Water poured above 
these intussusceptions escaped through them very slowly ; no fibrinous 
exudation ; descending colon vascular and thickened, and solitary glands 
enlarged. 

The irreducible character of the intussusceptions in the above cases 
was shown by the fact that they sustained weights which doubtless pro- 
duced greater traction than that exerted by the intestine in its normal 
action. That the displacement existed prior to the moment of death 
was shown by the symptoms in one of the cases and by the anatomical 
changes in both. In one the capillaries of the incarcerated mass were 
ruptured during the last days of life, so as to produce sanguineous stools ; 
while in the other there was intense congestion of the invaginated 
mucous membrane, while that portion of this membrane which was ad- 
jacent but not engaged was healthy. 

In both patients the symptoms were less severe than in ordinary 
cases, and they came on more gradually, for the invaginated intestine 
was not completely closed, so that it allowed the passage of fecal matter 
in one till the close of life, and in the other till near its close. At both 
of the autopsies water poured into the intestines above the invaginations 
passed slowly through them. 

Intussusception in the small intestines in the infant, commencing as 
the simple form, may become irreducible, and yet remaining pervious 
may continue for weeks without giving rise to severe or dangerous symp- 
toms. The following case was an example of this: 

Case. — Male child, died at the age of nineteen months, the last eleven 
of which he was under observation. The mother states that he had never 
been well since the age of one month, and that there had been little varia- 
tion in the symptoms of his disease. During the period in which he was 
under observation, he was ordinarily fretful, and frequently seemed to be 
in considerable pain. His stomach through this whole time w^as so irri- 
table that he rarely took more than three or four spoonfuls of nutriment 
without vomiting. There was usually more or less diarrhoea, but no ten- 
derness or distention of abdomen. He became slowly but gradually more 



INTUSSUSCEPTION IN LARGE INTESTINES. 798 

emaciated, and finally died in a state of extreme emaciation and exhaus- 
tion. He had no convulsions, and was conscious to the last. 

Sectio Cadaver. — Brain not examined; lungs healthy, except a circum- 
scribed portion which was inflamed at the summit of the right lung ; liver 
small and almost destitute of oily matter, as shown by the microscope. In 
the jejunum, about two feet below the stomach, was an intussusception 
two inches long, the intestine forming which seemed to have undergone no 
structural change. Above the intussusception the intestine was of small 
calibre, and entirely empty and pale; below the intussusception the intes- 
tine was somewhat larger than above, but it seemed quite healthy. The 
invagination was sufficiently pervious to allow water to pass through it, 
and it readily sustained the weight of two feet of intestine. From eight to 
ten inches below this intussusception there was another, which was imme- 
diately drawn out the moment the intestine was disturbed. The other 
abdominal viscera were healthy. 

There is uncertainty as to the duration of intussusception in the 
above case, but the symptoms indicated that it existed a considerable 
time prior to death. There was no strangulation, nor indeed any ap- 
preciable anatomical alteration in the coats of the intestine, but the fact 
that the invaginated mass sustained two feet of intestine, and required 
considerable traction for its reduction, shows that it was not a case of 
simple displacement occurring at the moment of death and without 
symptoms, but was an example of the variety with symptoms. 



Intussusception in Large Intestines. 

In most cases of intussusception occurring in infancy and childhood, 
the ileum is invaginated in the colon, or the first part of the colon is 
invaginated in the part succeeding it. Intussusception not infrequently 
begins in the prolapse of the ileum through the ileo-csecal valve, in the 
same way that prolapse of the rectum occurs through the sphincter ani. 
If death take place early, only a small portion of the ileum may have 
passed the valve. If the case be protracted, the tenesmus brings down 
more and more of the ileum, with its accompanying mesentery. The 
constriction of the valve, which acts as a ligature, soon prevents the 
further descent of the ileum ; and, the tenesmus continuing, the next 
step in the displacement is the inversion of the caput coli, which is 
drawn into the colon by the descending mass, and, unless the case ter- 
minate by sloughing or death, the ascending and transverse portions of 
the colon are successively invaginated. The records show that intussus- 
ception occurs as above stated in a large proportion of cases. In one 
case, among those which I have collated, the invagination began a few 
inches above the valve, so that the ileum constituted a small portion of 
the exterior of the mass. Occasionally the csecum is the part primarily 
inverted and invaginated, and, descending along the colon, it draws 
after it the ileum, which sustains its natural relation to the ileo-csecal 
valve. When this occurs the csecum is found at the lower end of the 
mass, and two orifices are observed, one leading through the valve, and 
the other into the appendix vermiformis. These two forms of invagi- 



794 INTUSSUSCEPTION. 

nation — that in which the ileum, passed through the ileo-csecal valve, 
successively inverts and draws after it the caput coli and the divisions 
of the colon, and that in which the caput coli is primarily invaginated, 
and descending along the large intestine, inverts the latter, and draws 
after it the ileum — constitute the vast majority of cases of this disease 
in the first years of life. 

I have notes of 45 fatal cases occurring under the age of twelve 
years, in which the portion of intestine first displaced is recorded. In 
4 of these the displacement was entirely in the small intestine, in- 
volving in no way the colon ; in 38 cases it commenced either by pro- 
lapse of the ileum through the ileo-csecal valve, or by the inversion of 
the csecum into the ascending colon, there being perhaps not much dif- 
ference in the relative frequency of these two modes ; in one case the 
invagination was confined to a segment of the transverse colon, in 
another to a segment of the descending colon, and in the remaining 
case to the lower part of the descending colon and the upper part of 
the rectum. In three instances the invaginated mass itself became 
invaginated, producing an intussusception of great thickness, and neces- 
sarily fatal. 

Intussusception is sometimes attended by so little constriction of the 
incarcerated portion that it remains pervious. In such a case life may 
be protracted for weeks or even months, without reduction of the dis- 
placement or any material change in it, the passage of fecal matter being 
sufficiently free for the maintenance of life. Death finally occurs in a 
state of exhaustion. Thus in one instance a child, four months old, lived 
six weeks after the symptoms of invagination commenced, and seventeen 
days " with a portion of the bowel protruding from the anus." It was 
found at the post-mortem examination that part of the ileum had de- 
scended through the entire colon, and had remained pervious. In a case 
related by Dr. Worthington 1 symptoms of intussusception were present 
for seven months before death, and during the last six weeks of life 
the invaginated intestine protruded frequently from the anus, and was 
replaced by the mother. In this case " the csecum was inverted, and 
descending through the colon to the lower portion of the rectum, car- 
ried with it the ileum and the entire colon, except the last ten or twelve 
inches." In another case the symptoms indicated a continuance of the 
disease for three, if not eight months. But such cases are exceptional. 
Ordinarily as the intestine becomes invaginated, its mesentery or meso- 
colon is also invaginated, and its veins compressed. The pathological 
state of the incarcerated mass soon becomes that of intense congestion. 
In infants, usually in a few hours, so great is the distention of the 
capillaries that they give way, blood escapes into the intestine, and 
passes from the bowels in scanty motions. On examining the invagi- 
nated intestine after death, if gangrene have not occurred, it is found 
of a uniformly intense red color, sometimes resembling to the naked 
eye a long and firm clot of blood. In those who die early no traces 
of inflammation are seen, but in more protracted cases the attrition 
between the serous surfaces excites local peritonitis. In none of the 

1 Anier. Jour, of Med. Sci. for January, 1849. 



INTUSSUSCEPTION IN LARGE INTESTINES. 795 

fifty-two cases which I have collated in which post-mortem examina- 
tions were made, did the inflammation extend more than a few lines 
beyond the invagination. Usually the intestine forming the exterior 
of the invaginated mass is much drawn together or puckered. In one 
case treated by myself, the entire large intestine which formed the exte- 
rior of the mass was compressed within a space of six inches or less, 
since about twelve inches of the ileum, doubled on itself, lay within the 
entire colon and protruded from the anus, the only part of the large 
intestine which was inverted being the caput coli. In one case six or 
seven inches of the ileum, which formed a portion of the exterior of the 
mass, were compressed within the space of one inch. 

The abdomen, at first of natural fulness and soft, usually becomes 
more and more distended till the close of life ; but in cases of much 
vomiting the distention is moderate. This fulness is due to gas and 
fecal accumulation above the invagination. The portion of the intestine 
below the displacement is ordinarily empty, except that in the infant it 
commonly contains mucus, mixed with more or less blood, which has 
escaped from the capillaries of the strangulated mass. 

There are few anatomical changes in this disease, which do not arise 
directly from the intussusception, and are, therefore, located either 
within the mass or in its immediate vicinity. In those who recover by 
the process of sloughing, the cicatricial contraction may give rise to 
symptoms and lesions of greater or less gravity. Thus the late Sir 
James Y. Simpson examined a child aged 9 years, who recovered with 
loss of ten inches of intestine, and at the meeting of the Medical 
Society 1 before w^hich the specimen was presented, remarked that there 
was unusual distention of the cutaneous veins of the patient, due prob- 
ably to such compressions of the ascending vena cava by the cicatrix, 
that the venous circulation w T as obstructed. Mr. Charles King 2 relates 
the case of a child aged 6 years, who, on the eleventh day of the dis- 
ease, voided the c?ecum and a part of the colon. Two days subsequently 
pulsation ceased in the left leg, and all that part below the patella be- 
came gangrenous. The patient gradually recovered with loss of the 
leg. The cause of this unfortunate sequela was doubtless compression 
from the cicatricial contraction of the artery which supplied the leg, and 
probably the formation of a thrombus. Dr. F. Bush 3 relates a case in 
which he was enabled to observe the extent and appearance of the 
cicatrix. The patient, aged twelve years, discharged from the bowels 
fifteen to eighteen inches of the ileum on the eighth day of the intus- 
susception, after which convalescence was rapid. Fourteen weeks later 
the child died from typhus fever, and at the autopsy " traces of the dis- 
eased bowels were visible by a contraction and puckering where the 
slough had taken place, and the parts united." But fortunately in 
most instances when the intestine sloughs and the child survives, no 
serious or permanent injury results from the cicatrization. The cicatrix 
stretches little by little, and accommodates itself to the surrounding parts. 

1 Trans. Medico-Chir. Soc, Edin. 

2 London Lancet for 1854. 

3 Lond. Med. and Phys. Journ. for December 18, 1823. 



796 INTUSSUSCEPTION. 

Symptoms. — The symptoms vary acoording to the age of the patient 
and the degree of strangulation. Pain in the abdomen, usually parox- 
ysmal, is among the first, and is one of the most conspicuous symptoms. 
It is often severe, resembling the pain of hernia, and abating only with 
the failing strength of the child. After the first few days, if inflamma- 
tion arise, the pain is continuous, though more severe in paroxysms. At 
first pressure upon the abdomen is tolerated, but afterward there is 
tenderness. This is due to the inflammation, which occurs in and 
around the invaginated mass, and it is, therefore, confined to the part 
of the abdomen in which the tumor lies. At this point also the abdo- 
men is more full than elsewhere, and not infrequently the physician can 
feel the invaginated mass and detect its exact location, and approxi- 
mately its extent. Sometimes, at an early period as well as late, cere- 
bral symptoms occur, as in a case related by Dr. Coggswell, 1 which 
terminated in convulsions and death on the second day. Convulsions 
are, however, comparatively rare, and the mind is generally clear till 
the last moment. In infants the countenance, in the intervals of pain, 
in the first stages of the complaint, is often placid and not indicative of 
any serious disease, but in older patients constant and severe local 
symptoms, referable to the intussusception, commence early. At an ad- 
vanced period, whatever the age, the countenance becomes anxious and 
haggard, the eyes hollow or sunken, the body loses its plumpness, and, 
if the case be protracted, becomes emaciated. 

Vomiting is rarely absent ; in thirty-nine out of forty-seven cases it is 
stated to have been present, in seven cases there is no record of this 
symptom, while it is recorded absent in only one case ; but in this case, 
the records of which are very meagre, death occurred on the second day. 
The vomiting becomes stercoraceous in a few days, and it ordinarily 
continues with greater or less frequency till the period of collapse. It 
relieves partially the distention. 

The appetite is impaired and often entirely lost. Infants at the breast 
commonly nurse, however, for several days, probably from thirst rather 
than hunger. 

In most patients one natural evacuation occurs from the bowels after 
the intussusception commences, and then obstinate constipation succeeds. 
This evacuation consists of the excrementitious matter below the invagi- 
nation. In children under the age of one year, scanty motions of blood 
mixed with mucus begin to occur in a few hours. In twenty-seven chil- 
dren under this age I find that twenty-four had such evacuations, occur- 
ring in most of them several times in the course of the day ; in two of 
the twenty-seven there is no record of this symptom, but in the remain- 
ing case it is stated to have been absent. Scanty evacuations of blood 
unmixed with fecal matter have been considered pathognomonic of in- 
tussusception in the infant, and we see the ground for such belief, but in 
exceptional instances the invaginated mass is partly pervious, and 
although the dejections may contain blood, they are also excrementi- 
tious. In our collection of cases are three examples of this in infants 
under the age of one year. One has already been referred to. In this 

1 London Lancet for July, 1853. 



DIAGNOSIS. 797 

case there was the rare anomaly of so large an opening through the 
ileo-caecal valve as to allow not only prolapse and descent of the ileum 
through the entire colon, so as to protrude six inches from the anus, but 
also fecal passage through it daily. 

In children above the age of one year, the capillaries of the invagi- 
nated intestine are not so frequently ruptured as under this age, and 
sanguineous evacuations are therefore less common. I have records of 
nineteen cases between the ages of one year and twelve, in only six of 
which it is stated that there were bloody motions, and in these the blood 
was not passed frequently, nor even in some cases daily, as in infants, 
nor in so pure a state, unless in two cases, the records of which are»not 
explicit on this point. Two of these six patients passed moderate 
bloody evacuations after protracted periods of constipation, one had fecal 
discharges with the blood through the entire sickness, and in one blood 
was passed at first, but finally the stools were entirely fecal. 

In those above the age of one year, obstinate constipation was ordi- 
narily present, no dejections, either bloody or fecal, occurring for several 
days, but there were a few exceptions. In three cases the bowels were 
relaxed. The ileum, in these three, had descended through the entire 
colon, or the larger part of the colon, and being pervious, the feces escaped 
from the anus without detention in the large intestine, or with detention 
only in its lower portion, and were therefore liquid. 

Tenesmus is another symptom. It is not always present, but in a 
large proportion of cases, even when the invagination is in the upper 
part of the large intestine, it is a frequent and distressing symptom. It 
often does not commence till there is a considerable amount of displace- 
ment, and it ceases when the strength is much reduced. 

The temperature of the surface is normal in the commencement of 
intussusception; but finally, as febrile reaction comes on symptomatic 
of the inflammation, it rises and continues above the healthy standard 
till the intestine sloughs, or till the stage of collapse occurs which ushers 
in death. The pulse, especially in the infant, is tranquil at first, but, 
whatever the age, it soon becomes accelerated from the paroxysms of 
pain, and subsequently from the inflammation which occurs in the in- 
vaginated mass. There is no disturbance of respiration, except that it 
is somewhat hurried from the fever, and from the pain felt in advanced 
cases on full inspiration. 

It will be seen that the symptoms vary in certain particulars, under 
the age of one year^ from those occurring over that age, but differences 
in the symptoms depend more on the degree of invagination and con- 
striction, that on the age and exact location of the disease. 

Diagnosis. — The diagnosis of intussusception is not, in general, diffi- 
cult, except at its commencement. When the inversion has reached 
that degree at which obstruction occurs, the symptoms are, in most 
cases, such that the disease can be readily diagnosticated. In the cases 
whose records I have collated a correct diagnosis was, with few excep- 
tions, made, and at an early period. In the infant, the disease for 
which intussusception is most frequently mistaken is dysentery, on ac- 
count of the tenesmus and the muco-sanguineous stools. In certain of 



7t>8 INTUSSUSCEPTION. 

the reported cases this mistake was not rectified until it was ascertained 
that purgatives produced no fecal evacuations. 

The symptoms which are commonly present, and which indicate the 
nature of the disease, are obstinate constipation, vomiting, paroxysmal 
pain referred to the seat of the disease, and tenesmus. In the infant, 
also, scanty evacuations from the bowels of mucus and blood, or of pure 
blood, are, as we have seen, an important diagnostic sign. It should be 
borne in mind, however, that in exceptional cases the displaced bowel 
may remain pervious, and the usual symptoms which possess diagnostic 
value therefore be absent. There may be no vomiting or tenesmus, and 
diarrhoea may even occur in place of constipation, as in the cases related 
above. As an aid to diagnosis, it should be stated that whatever the 
age of the child aifected with intussusception, clysters are often adminis- 
tered with difficulty, and are quickly and forcibly returned, on account 
of the resistance opposed by the invaginated mass. We have stated 
above that the seat and even extent of displacement can be ascertained 
in a large proportion of cases by digital examination of the abdominal 
walls. The tumor can be felt hard, elongated, and tender on pressure, 
so that the diagnosis is clear. If the invagination have extended to the 
lower part of the large intestine, it can usually be discovered by an ex- 
amination per rectum. 

Duration. — In the following table, the duration of the intussuscep 
tion in forty-nine cases is given, as nearly as it can be ascertained from 
the records : 



2 died the 1st day. 


1 died the 8th day. 


6 " " 2d " 


1 " " 10th « 


14 " «•' 3d " 


1 ' " " 14th " 


2 " " 4th " 


1 lived nearly a week, the exact 


5 " " 5th " 


lime not being given. 


2 " " 6th " 


1 lived 6 weeks. 


2 " " 7th » 


3, time of death not given. 


1 lived over a week. 


7 recovered. 



In two of the three cases in which the duration is not stated, the 
patient lived much longer than the usual period. One of these two, a 
girl of six years, having eaten raw carrots, was seized with pain in the 
abdomen, which lasted eight months, when she died. During the last 
three months she passed mucus and blood. In this case the caecum had 
descended to the anus, drawing with it the ileum, which remained per- 
vious. The symptoms indicated the continuance of the invagination for 
three months if not eight. The other patient was a boy, aged three 
years and four months, who complained of pain in the abdomen for 
many months, and occasionally vomited. During the last six weeks of 
his life, all the phenomena of invagination were present. In this case, 
also, the inverted caput coli had descended along the entire length of 
the colon, and at the autopsy it lay in the rectum. 

In West's Treatise on Diseases of Children (fifth edition, 1866, 
page 504), it is stated that death in this complaint always occurs within 
a week. The above statistics, however, show that there are exceptions 
to this statement, although a large majority do die within the first seven 
days. In thirty-three of the cases embraced in my statistics death oc- 



PROGNOSIS. 799 

curred within the first week, and in no fatal case in which strangulation 
was complete was life prolonged beyond the eighth day. In these cases 
of complete strangulation the average duration was 3.7 days, and the 
largest number of deaths occurred on the third day. Death on the first 
day is rare, but it occurred in two of the cases embraced in my statistics. 
Death at so early a period usually takes place in convulsions and coma. 

Prognosis. — Intussusception is in its nature so grave an accident 
that the physician called to a case should always explain its gravity to 
the friends. But, while death is the common result, there are three 
different modes of termination in which life is preserved. First, the 
reduction of the incarcerated intestine, with immediate relief. There 
can be no doubt that it is possible for intussusception, when recent, to 
be reduced by the unaided action of the bowels, in the same way as the 
common, simple intussusception in the jejunum and ileum, or as hernia 
is reduced, through the vermicular action of the intestines, for some- 
times, as in Dr. Coggswell's 1 case, the patients at some previous time 
have experienced the same symptoms as those which accompanied the 
attack, and which subsiding, they remained for a time in perfect health. 
This termination is probably rare, if the symptoms be sufficiently 
marked to necessitate treatment. Again, the intussusception may be 
cured by early and well-applied treatment. The physician often suc- 
ceeds in reducing the displaced intestine, even if the intussusception be 
in the upper part of the colon, if he be called sufficiently early, and 
employ the proper measures. 

A second mode of favorable termination is alluded to by certain 
foreign writers. The intussusception continues for a considerable period 
with the characteristic symptoms, and then, as Bouchut expresses it, 
" the vomitings gradually cease, the intestinal hemorrhage disappears, 
the strength returns, and the health becomes restored without the ex- 
pulsion of fragments of the intestine." What changes the displaced 
intestine undergoes in these protracted cases, which gradually recover 
without sloughing, have not been clearly ascertained, although they 
have been the subject of conjecture. According to Rilliet, a large pro- 
portion of favorable cases terminate in this manner. It does not appear, 
however, from the statistics which I have collected, that this is a com- 
mon mode of recovery. The clinical history of intussusception estab- 
lishes the fact that in a large majority of protracted cases there is 
either death or the third mode of favorable termination, namely, by 
sloughing. 

But we cannot reasonably expect recovery in young children through 
sloughing and the expulsion of the intestine ; since few have the requi- 
site strength for so tedious and exhaustive a process. The youngest 
child that recovered in this way, so far as I have been able to ascertain, 
was an infant thirteen months old, whose case was reported by M. 
Marage. With the exception of this case, the youngest was a boy, aged 
five years. The older the child, the greater, of course, the power of 
endurance, and the better the prospect of recovery. Of the fifty-two 
cases whose records I have collated, seven recovered by the sloughing 

1 London Lancet, July, 1853. 



800 INTUSSUSCEPTION. 

and expulsion of the mass. These children were of the ages of five, six, 
six, nine, eleven, twelve, and twelve years. The separation of the 
invaginated mass occurred in six of these between the sixth and twelfth 
days, with an average of nine and a half days. In the remaining case 
the time is not given. If, then, the patient can be carried through the 
first week without too much exhaustion, we may each day look for 
the discharge of the slough, the reopening of the bowels, and ultimate 
recovery. 

But in those cases in which the intussusception remains open, so as 
to allow the passage of fecal matter, recovery is improbable unless the 
displacement be diagnosticated early and properly treated. If the intus- 
susception continue, it becomes greater and greater from the absence of 
strangulation. Without inflammation and with little or no congestion 
of the displaced portion, and without the severe symptoms which occur 
in ordinary cases, the patient wastes away, having irregular evacuations 
and more or less abdominal pain, and finally dies in a state of emacia- 
tion and weakness. In the early stage of this form of displacement it 
is not improbable that injections or inflation, employed with sufficient 
force, will give relief, but if the early period pass without such treat- 
ment, cure is impossible by the ordinary methods. It is in such in- 
stances especially, to wit, those in which the displacement occurs with- 
out strangulation or inflammation, and in which fecal matter passes 
through the displaced mass more or less freely, that laparotomy is justi- 
fiable, and is likely to give relief, when injections and inflation have 
been employed in vain. Jonathan Hutchinson's successful performance 
of this operation in a child of two years, who had this kind of displace- 
ment, is known to most readers. 1 

The prognosis is most favorable when the displacement occurs in the 
lower part of the large intestine, for its reduction is then comparatively 
easy. An interesting case of this kind was observed and treated by Drs. 
O'Dwyer, Reid, and myself, in the New York Foundling Asylum, in 
1875. The child was a female, aged two years, and had had previous 
good health. The invaginated mass protruded like a prolapse, about 
four inches outside of the anus. It was cold, considerable hemorrhage 
had occurred from it, and the infant seemed in collapse. When the 
mass was returned so far as it could be carried within the pelvis, by the 
index finger, the lower end of it could still be felt like an os uteri. It 
protruded four or five times within twenty-four hours, but, by replace- 
ment so far as possible with the fingers, and the use of simple water 
injections, with the hips elevated, it was finally permanently reduced, 
and, with the use of stimulants, she soon fully recovered. 

Mode of Death. — This is different in different cases. It some- 
times occurs from collapse. At a meeting of the New York Patholo- 
gical Society, held December 10, 1873, 1 presented a specimen, showing 
intussusception occurring about one foot above the ileo-csecal valve, in 
an infant aged thirteen months. On the day before its death, its 
previous health having been good, it seemed ill, and vomited once or 
twice, but did not appear to be in pain. It had two evacuations from 

1 London Lancet, November 22, 1873. 



TREATMENT. 801 

the bowels, of the usual appearance, in the latter part of the day. On 
the following morning it was unexpectedly in collapse, and died within 
about twenty-four hours from the commencement of the sickness. At 
the post-mortem examination the cranium was not opened, but all the 
organs of the trunk were found normal except the intussusception. The 
mass involved in the displacement measured two and a half inches in 
length, and was slightly crescentic. The mucous membrane above and 
below it had the normal appearance, as did that of the external or in- 
carcerating portion of the mass, while that of the incarcerated part was 
deeply injected. Water poured into the intestine above the invagina- 
tion was wholly arrested by it. 1 But in the majority of instances death 
occurs from asthenia, which comes on gradually, but increases rapidly 
in consequence of the pain, vomiting, and imperfect nutrition. Children 
dying in this way may have convulsive movements more or less marked, 
but the prevailing characteristic as death approaches is extreme exhaus- 
tion. In exceptional instances the life of the sufferer is cut short by 
convulsions before the stage of exhaustion is reached. Thus a child 
aged three years, whose case was reported by Dr. Isaac Thomas, 2 and 
another, aged two years, whose case was reported by Dr. Coggswell, 3 
died in convulsions on the second day. 

Treatment. — It is unfortunate, in cases of intussusception, that the 
time in which treatment can be of most service is likely to pass by before 
the true condition of the intestine is detected. Invagination being com- 
paratively rare, the patient is generally on the first day treated for colic 
or dysentery or some other common affection of the bowels ; and it is 
often not till the second day, when the intestine has become incarcerated, 
that the physician accurately diagnosticates the disease. The purgative 
medicines often given in the commencement injure the patient. In fact, 
both reason and experience teach us the impropriety of using purgatives 
in this complaint. Cathartic remedies act as a vis a tergo, and may cause 
still further descent of the inverted intestine. Yet such powerful agents 
of this class as quicksilver have been employed. It was administered 
in two doses of one ounce each in one of the cases embraced in my statis- 
tics, but none of the mineral passed the bowels. At the post-mortem 
examination a considerable part of it was found in small globules, coated 
with a black layer consisting of the sulphuret or black oxide of mercury, 
in the intestine above the intussusception. It need not be added that the 
case was speedily fatal. 

The proper treatment of intussusception consists in attempts to reduce 
the displacement by pressure from below. The pressure may be applied 
either by liquid injections into the rectum or by inflation of the lower 
intestine by air or gas. 

Injections should be made with lukewarm water, for cold or hot water 
may cause contraction of the muscular fibres of the intestine, and increase 
the constriction. The child should be placed in bed, or in the nurse's 
lap, with the nates elevated 45°. With the common India-rubber, or 

1 New York Medical Record, April 1, 1874. 

2 Araer. Med. Recorder, 1823. 

3 London Lancet, July, 1853. 

51 



802 INTUSSUSCEPTION. 

bettor the fountain-syringe, and the aid of an assistant, the liquid should 
be gently thrown into the rectum until the abdomen is somewhat dis- 
tended. By carrying the fingers, firmly but gently applied upon the 
abdominal walls, along the direction of the colon, the liquid is made to 
press against the lower end of the intussusception. The same gentle- 
ness and perseverance are required in kneading and pressing the abdom- 
inal walls as in the treatment of hernia, by taxis. If the invagination 
be in the descending colon, probably only a small quantity of the liquid 
can be injected, and it may be forcibly returned, but by repeating the 
injections a sufficient quantity can ordinarily be introduced to obtain 
the full effect of the mode of treatment. There is also sometimes an in- 
creased irritability of the rectum, even when the intussusception is at 
the upper extremity of the large intestine, so that tenesmus and expulsive 
efforts follow the introduction of the instrument. The assistant can aid 
in overcoming this by pressing the soft parts of the nates around the 
instrument. 

If the injection fail to reduce the displacement, it may be repeated 
after allowing the patient to rest for a while- In the New York Medical 
Journal for May, 1875, is the history of an interesting case, which was 
treated by Drs. Church and Warren of this city, and is reported by the 
latter. The infant was seven months old and had the usual symptoms 
such as frequent paroxysmal pain in the abdomen, vomiting, tenesmus, 
scanty muco-sanguineous stools. On the third day injections were twice 
employed without result, but on the fourth day an injection of ten or 
twelve ounces reduced the displacement, and the infant recovered. In 
a second case treated by Dr Warren the age was nine months, and a 
tumor appeared a little above the umbilicus a few hours after the com- 
mencement of the symptoms. The following is Dr. Warren's account 
of this interesting case, which will give a clear idea of the proper mode 
of treatment : 

" The patient was looking very pale and prostrated, the pulse was 
quick and feeble, and the skin cold. I at once determined to use fluid 
injections, and, with the little patient placed in a semiprone position in 
his mother's lap, with an ordinary Davidson's syringe I commenced in- 
jecting tepid soap and water, but after perhaps a gill had been thrown 
into the rectum, it w r as almost immediately rejected, very highly colored 
with blood, and mixed with it a very small quantity of mucus and fecal 
matter ; the latter, by the way, not hardened, but of the consistency of 
soft putty. In a second attempt the fluid was retained longer, but was 
after a little while discharged, with more blood and mucus, but with 
much less tenesmus and pain. 

" When, soon after, I made my third attempt, the child's chest was 
rested upon the side of its mother's lap, with the lower extremities 
elevated by an assistant, so that the position was at an angle of about 
45°, anus upward. This time I injected the fluid very slowly, in order 
to avoid, if possible, the irritation caused generally by the frequent 
emptying and refilling of the syringe (which, by the way, is a very 
serious hindrance to the successful use of this syringe, and which renders 
it much inferior to the fountain or hydrostatic). In this manner I suc- 
ceeded in injecting, as I estimated at the time, perhaps ten or twelve 



TREATMENT. 803 

ounces, and during the operation the child gradually became more quiet, 
and had, when I ceased, fallen asleep. Then, with the direction that 
occasional doses of tinct. opii campli. should be administered during the 
night, to control, if possible, the peristaltic action of the intestines, I left 
him. 

" On the following morning, to my surprise, I found the child sleep- 
ing quietly and naturally, and I was informed that at about 5 A. M. (six 
hours after my visit) he had a movement of the bowels, which was saved 
for my inspection, and consisted simply of the enema, slightly colored 
with fecal matter. From that time he seemed to be entirely free from 
pain, and six or seven hours later had a natural passage, after which re- 
covery progressed rapidly, and in a few days he was discharged well." 

The following case is interesting as showing success from the use of 
injections after the lapse of two days, in a severe case, which had re- 
sisted treatment on the first day. The good result was apparently in 
great part due to the manipulation which was made so as to press the 
water against the course which intussusceptions are known to take. 

On September 10, 1876, I visited, with Dr. Gillette, a nursing infant, 
aged nine months, whose history was as follows : It was habitually con- 
stipated, but it continued in its usual health till September 8. on which 
day it was carried by its nurse to one of the city parks. After its re- 
turn it began to be fretful ; it vomited, and seemed to be in pain. It 
continued to vomit frequently, especially after nursing, or taking drinks, 
and in the ensuing night passed two scanty stools of mucus and blood 
without fecal matter. In the morning of September 9th, Dr. G. was 
summoned, who found the pulse 180, and temperature 102°, and the 
matter vomited greenish like bile. In the evening the temperature was 
102f°. Dr. G. diagnosticated intussusception, and employed injections 
of water, but they were returned without bringing fecal matter, and 
without apparent result. He also administered opiates by the mouth. 

September 10th, temperature 102f° ; features pallid, beginning to 
have a pinched or sunken appearance, and indicative of much suffering; 
no nutriment is apparently retained on account of the frequent vomit- 
ing, and the bowels are obstinately constipated. As the symptoms in- 
dicated rapid sinking and collapse, consultation was called at 1 P. M. It 
was impossible to determine certainly, through the abdominal walls, on 
account of the distention, whether there was any tumor, but it was my 
opinion, and the opinion of one of the other physicians, that a tumor, 
hard and inelastic, could be felt nearly in the median line, between the 
umbilicus and the symphysis pubis. At about 5 P. M. the shoulders of 
the little patient were lowered, and the nates elevated, so that the trunk 
formed an angle of perhaps forty-five degrees with the horizontal, and a 
large quantity of tepid water was gently passed into the intestine through 
Davidson's syringe, with the vaginal nozzle attached. It was impossible 
to estimate the quantity retained, since a considerable part of it escaped, 
although the anus was firmly pressed around the instrument. 

When the abdomen was distended as fully as seemed justifiable, the 
nates being still elevated, and the licpiid retained, so far as possible, by 
firm pressure upon the anus, the abdomen was firmly and deeply kneaded 
by the hand, the movements being made chiefly from the right lumbar 



804 INTUSSUSCEPTION. 

toward the right inguinal, and from the right inguinal toward the hypo- 
gastric region. The kneading was continued perhaps eight or ten min 
utes, and the water, which contained no perceptible amount of fecal 
matter, blood, or mucus, was allowed to escape. 

After this operation the child became quiet, slept, and the vomiting 
ceased. At our next visit at 7 p.m., although the severe symptoms 
had in great part abated, and the countenance had lost that pinched 
and suffering aspect which was so prominent before, it was deemed best, 
in consultation, to repeat the injection, and this time through a rectal 
tube, which was introduced further than the nozzle employed at the 
preceding visit. The body was placed in the same position as before, 
and the abdomen kneaded in the same manner. The water, when 
allowed to return, brought no fecal matter, but the last that flowed con- 
tained two shreds, the largest about one inch in length by two lines in 
width, resembling matted and nucleated epithelial cells. It was believed 
that they were composed of such cells, with perhaps some of the mucous 
membrane to which they were attached, and that they were detached 
from the invaginated portion. An opiate mixture was now prescribed, 
to be given sufficiently often to relieve any restlessness, and keep the 
patient quiet, and a flaxseed poultice was applied over the abdomen. 
On the following day the temperature was 103 J-°, pulse 158, and the 
abdomen somewhat distended; but the vomiting had ceased, and there 
had been two fecal evacuations since our last visit. The intussuscep- 
tion had been relieved, the inflammatory symptoms soon abated, and 
the infant's health was fully restored. 

Injections in order to be effectual, and give promise of success, must 
be aided by gravitation. Unless the nates be so elevated as to obtain 
the benefit of this hydraulic principle, I am convinced that inflation is 
more likely to reduce the displacement, and if, after sufficient trial of 
injections, relief be not obtained inflation should be employed. Infla- 
tion produces an equable and effective distention of the external or in- 
carcerating portion of intestine, and cases of cure by inflation have been 
reported after injections had failed. Treatment by inflation, which in- 
deed ought to occur to any intelligent physician appreciating the ana- 
tomical condition of the parts, as the correct mode, was prominently 
brought to the notice of the profession in modern times by Mr. Samuel 
Mitchell. 1 

"I take the liberty," he writes, "of suggesting to the profession, 
through the medium of your valuable periodical, the trial of inflating 
the bowels by means of a glyster-pipe attached to a common pair of 
bellows ; it has fallen to my lot to witness several of these most distress- 
ing cases in children ; the nature of the obstruction was foretold during 
life, and unfortunately verified by post-mortem examination. The last 
case of the kind which came under my care, about two years since, pre- 
sented all the usual symptoms : intolerable restlessness, the most obsti- 
nate sickness, the singularly distressed state of countenance, and shrun- 
ken features. The usual remedies were had recourse to, viz., warm 
baths, glysters, anodyne frictions over the abdomen, etc., but without 

1 London Lancet for March 17, 1838. 



TREATMENT. 805 

avail. As a forlorn hope, I made trial of inflation by the above means, 
with the most happy result. The sickness immediately ceased; the 
child within an hour passed a natural stool, and in the morning was 
almost without ailment." 

This mode of treatment is termed novel in the Lancet^ but it is really 
as old as the time of Hippocrates, who speaks of throwing air into the 
bowels, by which flatulence is imitated (flatus immitatur). 1 Haller 2 also 
recommended the same treatment: " Flatus etiam immissus celerrime 
susceptionem dispellet." Dr. David Greig 3 relates five cases of success- 
ful treatment of intussusception by inflation. The first, an infant six 
months old, previously in good health, suddenly became very fretful, 
apparently having severe paroxysmal pain in the abdomen. She had 
vomiting, and finally tenesmus, with bloody evacuations. Warm water 
enemata could not be employed on account, the writer thinks, of the 
spasmodic action of the intestines, and an abdominal tumor could be 
felt near the umbilicus. Castor oil and a purgative powder, and ene- 
mata of water having been employed in vain, and the case becoming 
really critical on the second day, inflation was resorted to. The writer 
says: " The nozzle of a small pair of bellows was introduced into the 
anus, and air injected to a considerable extent. Contrary to our expec- 
tation, the air passed readily into the bowel, and seemed to give the 
child great relief. After the injection it lay very quiet, as if asleep, 
and evidently quite free from pain. In about twenty minutes from the 
time the air injection was administered, a slight rumbling noise was 
heard in the child's abdomen, followed by a crack so loud and distinct as 
to alarm the attendants in the room, who thought something had burst 
in the child's bowels. The child, however, continued as if asleep, and 
free from pain, and in about half an hour a large feculent stool, slightly 
mixed with blood and mucus, was passed without pain. During the 
night the child rested pretty well, had no return of vomiting, took the 
breast as usual, and in two days was quite well. 

Another child, nine months old, treated by Dr. Greig, presenting 
nearly the same symptoms and the abdominal tumor, also obtained re- 
lief by inflation, after castor oil and enemata had failed to produce any 
benefit. 

An apparatus for the production and injection of carbonic acid gas 
has been invented by Schultz and Warker, of this city, and is manufac- 
tured by them. It consists essentially of two glass chambers, one over 
the other. In the lower one a bicarbonate is placed, and in the upper 
an acid in a liquid state. By the gradual admixture of the two, car- 
bonic acid is set free. An elastic tube conveys the gas from the lower 
chamber. The apparatus has been used by physicians of this city for 
the reduction of intussusception and other purposes, and is a useful in- 
vention. 

The same firm, and several others in this city, prepare for the shops 
large bottles of highly charged carbonic acid water, from which when 

1 Hippocrates's Works, translated from the Greek by Grimm, 4bd., page 198. 

2 Physiologia Corporis Humani, torn. vii. p. 95. 

3 Edinburgh Medical Journal, October, 180-4. 



806 INTUSSUSCEPTION. 

inverted a powerful current of carbonic acid gas can be obtained. Two 
or three of these bottles, with a portion of the tube from Davidson's 
syringe, which can be readily attached to the stem from which the gas 
escapes, constitute all that is required for an ordinary case. 

The following cases, whiclul treated with Dr. Buchler, of this city, in 
1871, show what may be achieved by inflation, and also the unfavorable 
result which must inevitably occur in certain cases. A German infant, 
five months old, nursing, began to be fretful, crying often, on March 7, 
and before night passed a scanty motion of blood. The symptoms con- 
tinuing, I was asked to examine the infant on the 10th, and learned the 
following facts: It had vomited daily, had had daily scanty but infre- 
quent stools, consisting chiefly of blood, accompanied at first by tenes- 
mus, but not within the last day ; it continued to nurse, but was be- 
coming thinner and weaker, and was evidently in pain. The symptoms 
indicating the nature of the disease, the abdomen, which was not dis- 
tended, was examined for the tumor, which was found in the right side 
in the site of the ascending colon, apparently about one and a half to 
two inches in length; pulse 124 in sleep; no cough. An ineffectual 
attempt was made to reduce the intussusception by a very rude and 
imperfectly constructed apparatus (the bellows), when from the lateness 
of the hour further treatment was postponed till early the following 
morning. 11th. Tumor still detected in the right lumbar region ; 
pulse 120 asleep, 150 awake. By means of Schultz and Warker's 
apparatus, the intestines were inflated so as to produce very decided 
prominence of the abdomen, and the abdomen gently kneaded. After 
some minutes the gas was allowed to escape, when the tumor had disap- 
peared. In a few hours, a natural evacuation occurred from the bowels, 
and the infant has remained well since. 

The second case ended unfavorably, although the symptoms were 
apparently no more grave than in the case just related, and had con- 
tinued a shorter time. This infant was also of German parentage. The 
tumor, firm and elongated, could be distinctly felt in the left lumbar 
region. In this case the inverted bottles of carbonic acid water were 
employed, and when, after considerable delay and kneading of the abdo- 
men, the gas was allowed to escape from the intestine, the tumor had 
disappeared. A few hours afterward convulsions occurred, ending 
fatally. At the autopsy the invaginated mass, which was too firmly 
strangulated to admit of reduction by inflation, was found in the epigas- 
tric region, having been carried up from its former position by the infla- 
tion of the intestine below. It consisted of the terminal part of the 
ileum, which had passed through the ileo-csecal orifice, and had become 
incarcerated in the ascending colon, and, as is not unusual in these cases, 
the action of the intestines had changed the location of the tumor in the 
abdomen from the right to the left side. 

Whether air or carbonic acid be employed, it is necessary to produce 
distention of the intestine to its fullest extent below the seat of the 
complaint, without endangering rupture, and of course the sooner it is 
used the better the chance of success. In a few days the displaced 
intestine has, in a large proportion of cases, become so firmly incarce- 
rated, and has descended so far, that attempts to replace it, either by 



TREATMENT. 807 

injections or inflation, are unsuccessful; still, even at a later period, a 
persevering attempt should be made if it have not previously been 
tried. If injections and inflation fail to effect the desired result, the 
employment of quicksilver, by the rectum with the thighs elevated, has 
been suggested to me as worthy of trial by a physician of large practice 
in this city, who has had considerable experience with intussusceptions. 
This may be a useful suggestion, especially if the invagination be in the 
descending colon. 

If the modes of treatment which I have recommended above fail to 
give relief when perseveringly and sufficiently employed in a case of 
acute intussusception, the patient's state is one of extreme peril, and the 
prognosis is unfavorable. Yet recovery is possible in one of two ways, 
namely, by incision through the abdominal walls (laparotomy), and 
reduction of the displacement by the fingers within the abdominal 
cavity ; and secondly, by sloughing of the invaginated mass, and union 
by adhesive inflammation of the ends of the intestine which have pre- 
served their vitality. Atrophy of the imprisoned part so seldom occurs 
in a case which has resisted injections and inflation, that it need not be 
considered, in this connection, as a mode of recovery. 

Laparotomy has been successfully performed in a child aged two 
years, as I have stated above, by Dr. Jonathan Hutchinson, of London. 
The case was one of those exceptional ones in which great displacement 
had occurred without strangulation. It had continued as indicated by 
the symptoms about one month, and a portion of the intestine termi- 
nating in the ileo-csecal valve had protruded several inches from the 
anus. u The patient was anaesthetized by chloroform, and the abdomen 
was opened in the middle line below the umbilicus. The intussuscep- 
tion was then easily found, and as easily reduced. The after-treatment 
consisted only in the administration of a few mild opiates, and the child 
made a rapid recovery." 1 In a case of this kind, there can be no doubt 
of the propriety and necessity of laparotomy as a last resort, for there 
being no strangulation, sloughing could not occur, and death sooner or 
later, from exhaustion, must be the result. Cases of this sort have usu- 
ally been left to perish, after the ordinary modes of relief have failed. 
Thus as far back as 1784, M. Robin published 2 the case of a child aged 
3 J years, who died after the lapse of three months, with a caecum pro- 
truding from the anus; and in the Amer. Journ. of Med. Sci. for 1849, 
Dr. Worthington published a similar case, in which a child aged three 
years and four months lived a longer time. In these days of anaes- 
thetics, and with the brilliant success of Hutchinson, a physician would, 
in my opinion, be reprehensible if he allowed a child aged two years or 
over, with this form of displacement, to perish without strongly advis- 
ing laparotomy. 

But the question arises, whether in those more frequent cases of 
intussusception in young children in which, after the displacement has 
continued a few hours, there is such firm constriction of the invaginated 
mass that the patient suffers much pain and constitutional disturbance, 

1 London Lancet, November 22, 1873. 

2 M6m. de l'Acad. de Ghirurg. 



808 INTUSSUSCEPTION. 

and probably passes bloody stools, and injections and inflation have 
failed to reduce the displacement, laparotomy is justifiable. This 
operation, in the case of infants, has heretofore been regarded as so 
dangerous, and so likely in itself to prove fatal, that the profession have 
generally considered it unjustifiable, believing that, although death was 
nearly certain without it, the performance of it did not increase the 
chances of a favorable result. Dr. J. B. Sands, of New York, has 
recently shown that laparotomy is justifiable, as a last resort, for the 
relief of this form of intussusception, even in the youngest infants; 
and in the following case, recorded in the New York Medical Journal, 
June, 1877, saved the patient, who doubtless would otherwise have 
perished. 

On March 11, 1877, an infant of six months suddenly presented the 
characteristic symptoms of intussusception, such as tenesmus, abdominal 
pain, vomiting, and bloody stools. A few hours later, when Dr. Sands 
was called, the pulse was rapid and feeble, with symptoms of collapse. 
An elongated tumor could be felt in the abdomen, extending from the 
left iliac region to the left hypochondrium, inelastic, tender on pressure, 
and dull on percussion. The lower end of the invaginated mass could 
be readily touched by the finger introduced into the rectum. The usual 
methods to effect reduction were at once employed with partial success, 
for the tumor disappeared from the site where it had been discovered, and 
was reduced to a small and firm mass, on a level with the umbilicus, but 
it resisted any further attempts to effect its reduction. 

Dr. Sands then, having etherized the patient, made an incision in the 
median line of the abdomen, extending downward about two inches from 
a point a little below the umbilicus. Through this opening, proceeding 
cautiously, and using as little violence as possible, he was able, after 
some delay, to reduce the displacement. The invaginated mass, which 
was only one and a half inches in length, consisted of the terminal por- 
tion of the ileum and caecum, which had entered the ascending colon. 
The wound was closed by five silver sutures, which embraced the peri- 
toneum, and the patient made a good recovery. The operation was 
performed eighteen hours after the commencement of symptoms. 

Dr. Sands has collected the statistics of twenty cases of laparotomy 
for intussusception occurring at different ages, in which the result was 
stated Of these, seven recovered, or one in three ; but he judiciously 
remarks, considering the gravity of the operation, that it is doubtful 
whether future statistics will show so favorable a result of laparotomy 
for this displacement as to justify the frequent use of the knife. For 
facts and statistics relating to this subject the reader is referred to an 
able and elaborate paper by Dr. Ashhurst. 1 

It is obvious that the earlier the displacement is recognized, the 
greater the probability of the reduction by the judicious use of injections 
and inflation, and it is seen from cases related above that this treatment 
may be successful as late as the second or third day, after previous at- 
tempts to reduce the intussusception by the same means have failed, and 
when there is that degree of strangulation that bloody stools occur. But, 

1 American Journal of the Medical Sciences for July, 1874. 



T R E A TMENT. 809 

as my own experience has shown me, there is also inevitably a large 
proportion of cases in which the use of injections and inflation, however 
judiciously and perseveringly made, totally fail, and it seems to me, in 
the light of present experience, that when pressure from below by water, 
air, or gas, which is the only efficient mode of treatment short, of the 
knife, has been tried sufficiently long and often without result, that it is 
the duty of the physician to seek surgical advice in reference to lapa- 
rotomy, as lie would in a case of hernia, especially since, under Lister's 
antiseptic method, the danger from severe operations appears to be con- 
siderably diminished. It may be added that laparotomy performed on 
the first or second day will be much more likely to save life in ordinary 
cases than if performed later, since the strangulated intestine is soon 
badly damaged, and a local peritonitis is likely to be developed any time 
after the first forty-eight hours. 

When an intussusception has reached that stage in which active inter- 
ference is no longer proper, the physician can only prescribe opiates, 
with sustaining measures and an emollient poultice over the abdomen, 
and must await the result. The diet should consist of beef juice and 
other concentrated nutriment, which leaves little residuum. Vomiting, 
which is so common, is best controlled by bismuth and opiates ; convul- 
sions require the bromide of potassium, and an enema of three to five 
grains of chloral hydrate, dissolved in a little water. 



SECTION IV. 

DISEASES OF THE GENITOURINARY ORGANS. 



Uric Acid Infarctions. 

Infarctions of uric acid or the urates are very common in newborn 
infants. They are seen, if an opportunity of examining the kidneys 
occurs, as yellowish-red lines in the tubules of the kidney, or lying in 
the pelvis, forming small yellowish granules. As they are washed away 
by the urine, we often find them upon the diaper. The irritation pro- 
duced by these infarctions sometimes causes painful micturition. Chil- 
dren a few months old, often fret or cry from pain during urination, in 
consequence of the irritating action of the uric acid, while in the in- 
tervals between the passing of water they may or may not be free from 
suffering. Perhaps they pass only a few drops of urine with straining, 
and in it we find crystals of uric acid or the urates. Urine Highly acid 
from the presence of this substance, causes a burning pain in the urethra, 
and sometimes redness not only of the urethra, but even of the labia 
over which the urine flows. Although infants, perhaps, suffer most 
from this cause, the same condition not infrequently occurs in older 
children. Their urine previously normal, becomes unduly acid from 
some error in feeding or in the digestive process, and uric acid crystals 
or concretions form. An exaggerated secretion of mucus occurs from the 
surface of the bladder or from the urinary canal, in consequence of the 
irritation produced by the acid, and sometimes pus-cells are also seen 
under the microscope mixed with the mucus. 

The state of the urine described above should be at once rectified, for 
it furnishes the conditions in which calculi form either in the pelvis of 
the kidney, or in the bladder. Urine unduly acid and irritating, prob- 
ably at first causes catarrh of the delicate membrane lining the tubules 
and pelvis of the kidneys, and if the irritation be sufficiently severe, the 
catarrh extends along the ureters to the bladder, causing a degree of 
cystitis. Now a catarrh of the pelvis of the kidney or the bladder, 
greatly increases the tendency to the formation of calculi, since the 
crystals become imbedded in the mucus which serves to agglutinate 
them. Uric acid when so abundant in the urine as to cause symptoms, 
should be at once treated, and the acid neutralized by an alkali. The 
liquor potassae, employed as recommended in our remarks on the treat- 
ment of enuresis, is the best alkali for this purpose. For an infant of 
one year, two drops sufficiently diluted in mucilage will be sufficient, 
repeated in three or four hours. 
(810) 



ENURESIS. 811 



Enuresis. 



Enuresis, or incontinence of urine, is a common and troublesome 
infirmity in children. It occurs both in boys and girls, but is more 
common in the former than in the latter. In many children it dates 
back to infancy ; but others have a respite from it in the years im- 
mediately succeeding infancy, until the sixth or seventh year, when it 
returns. It may be diurnal as well as nocturnal, interfering seriously 
with the comfort of the child, and rendering his schooling inconvenient ; 
but the annoyance which it causes is commonly most at night, and it is 
for nocturnal enuresis that the physician is most frequently consulted. 
The child may pass his urine in bed every night, or even more than 
once each night, or there may be occasional nights of immunity. 

The bladder consists of three concentric coats. 1. On the outside, 
the peritoneal, which covers the posterior, the superior part of the 
lateral, and the anterior aspects of the organ. 2. The muscular, which 
chiefly concerns us at present, and which consists of two layers — the 
one external, the fibres of which have a general longitudinal direction ; 
the other internal, whose fibres are circular. The circular fibres become 
more abundant, producing greater thickness of this layer at the urethral 
orifice, and they extend a distance over the' urethra. This increase in 
the number of circular muscular fibres at the urethral orifice constitutes 
the sphincter vesicae. The fibres in the muscular coat of the bladder 
are unstriped, and are not under the control of the will. 

A second sphincter, which aids materially in the retention of urine, 
is formed by the compressor urethral This muscle, arising by apo- 
neurotic fibres from the ramus of the pubes, surrounds the whole mem- 
branous portion of the urethra, extending from the prostate to the 
bulbous portion. The compressor urethrae is a striped muscle, and its 
action is therefore controlled by the will. Certain accessory muscles 
influence the retention as well as the expulsion of urine, to wit, the 
levator ani, accelerators urinae, and the abdominal muscles, 

Nerves. — The muscular coat of the bladder receives its nerves from 
the hypogastric plexus, which belong to the sympathetic system, although 
filaments enter the plexus from the spinal system. The innervation of 
the bladder is, therefore, twofold — that derived from the sympathetic 
system predominating over that from the spinal system, as shown by the 
relative number of filaments from the two sources. According to Belfield, 
the spinal centre of the motor nerves of the bladder is in the vicinity 
of the third lumbar vertebra ; but Budge, in his experiments on rabbits, 
locates it in this animal in the vicinity of the fourth lumbar vertebra. 
The spinal centre of the nervous supply of the bladder, says Coulton, 
" is connected with the brain by a strand of fibres, which may be traced 
from the cerebral peduncle along the anterior columns of the spinal 
cord." The neck of the bladder, including the sphincter vesicae, derives 
nervous fibres directly from the anterior or motor roots of the third, 
fourth, and fifth sacral nerves ; and it is more abundantly supplied with 
nervous filaments than is the muscular coat of the organ. That the 
sphincter vesicae is under the control of the will, is, therefore, apparent 



812 DISEASES OE THE GENITO-UKINAR V ORGANS. 

from the anatomical characters, since a strand of fibres connects the 
peduncles with the motor centre of the bladder in the spine, and this 
centre connects with the sphincter through the spinal nerves. In 
normal urination, the sphincter is relaxed by the volition of the indi- 
vidual, while the muscular coat of the organ, being under the control of 
the sympathetic system, and involuntary in its action, expels the urine 
as soon as the sphincter is open. 

The pudic nerve also sustains an important relation to the function 
of the bladder. Arising from the sacral plexus, it is distributed "to the 
base of the bladder, the prostate, the integument of the penis, scrotum, 
and perineum, the urethral muscles and mucous membrane, and the 
sphincter of the anus ; in the female, the uterus, vagina, and vulva, are 
supplied by branches of the same nerve. ' ' Knowledge of the distribution 
of the pudic nerve enables us to understand the manner in which dis- 
ease or abnormal conditions of the genital organs and anus disturb the 
functions of the bladder. Irritation of the inferior branches of this 
nerve affects the action of the superior branches, or those which supply 
the base of the bladder and the urethral muscles, so as to produce in cer- 
tain patients dysuria, or incontinence, or both. 

Etiology. — In all cases the urine should be examined, since the 
cause of the enuresis is often discovered in the deviations in it from the 
normal state which are apparent on inspection. The chief causes may 
be grouped as follows, but often two or more of them are present in the 
same case : 

1. Too great acidity of the urine. The urine, in its normal state, is 
acid from the presence of the acid phosphate of sodium (Robin), but in 
certain conditions the acidity becomes so great that the urine is unduly 
stimulating to the surface of the bladder. Now, stimulating or irri- 
tating urine causes the bladder to contract, just as an irritating sub- 
stance in the intestines increases the peristaltic and vermicular move- 
ments of this tube. Excessive acidity of the urine is commonly due to 
the presence of uric acid, resulting from decomposition of the urates ; 
but in certain conditions lactic and hippuric acids, resulting from faulty 
digestion, appear in the urine (Robin) ; urine unduly acid renders its 
retention difficult, except in moderate quantity, so that enuresis results. 

2. Increased quantity of urine. This sometimes occurs from the free 
use of liquids, as of water or of milk. Renal disease, attended by an 
exaggerated excretion of urine, sometimes produces enuresis. Henoch 1 
says : " I would advise you never to omit an examination of the urine, 
because cases of diabetes mellitus and chronic nephritis are known, 
which were first manifested by nocturnal incontinence." 

3. A vesical calculus. This is an infrequent cause, but when present 
it is likely to produce both diurnal and nocturnal enuresis. If mictu- 
rition be frequent and painful by day and by night, if the urine contain 
a large amount of mucus or muco-pus, so as to render it turbid, and if 
the dysuria and frequent urination be not soon relieved by treatment, a 
calculus is probably present. In such cases the bladder should, of 
course, be sounded by the proper instrument to render diagnosis 
certain. 

1 Diseases of Children; page 257. 



ETIOLOGY. 81o 

4. The muscular coat of the bladder may have an exaggerated con- 
tractile power in itself, and not imparted to it by any extraneous stimu- 
lating agency. The surrounding conditions may be normal, while the 
bladder is hypersensitive, so as to contract with undue energy by 
ordinary stimulation. The fault is in the bladder itself, whose func- 
tional activity is in excess ; this appears to be the most common cause of 
enuresis in children. It is the condition of the bladder which Trousseau 
had in mind when he wrote : " I repeat that the nocturnal incontinence 
of urine is a neurosis, and I now add that it is a neurosis manifesting 
itself by excessive irritability of the bladder ; in fact, the immediate 
cause of incontinence is this excess of irritability in the muscular fibres of 
the bladder." As Bretonneau pointed out, children with enuresis from 
this cause, habitually pass urine in a full and rapid stream, and, there- 
fore, in less time than other children, showing that the contractile power 
of the muscular coat is in excess. From the fact that belladonna relieves 
so many patients, we infer that irritability of the muscular coat is a 
common cause of enuresis in children, since this agent acts by dimin- 
ishing muscular contractility. 

5. Weakness of the muscular fibres which constitute the sphincter of 
the bladder. Diminished tonicity of the sphincter muscles does not occur, 
or it occurs very rarely in those who have had previous good health, and 
are robust. Ordinarily, children affected by enuresis from this cause 
are in habitual ill health. They have had long and prostrating sickness, 
which has diminished muscular tonicity, or they have local disease in 
the spine, or in the course of the spinal nerves, which has impaired the 
innervation of the sphincter. Sometimes incontinence of feces is also 
present, and examination of the sphincter ani, by introducing the finger, 
shows that its contractile power is insufficient. We infer the presence 
of atony of the sphincter vesicae from the atony thus easily discovered 
of the sphincter ani. As an example of enuresis from atony of the 
sphincter vesicae, we may mention the case of a boy of thirteen years, 
who had " a flat doughy tumor" at the lower end of the dorsal verte- 
brae, in the middle of which a deficiency in the bony arch which covers 
the spinal cord, was detected by the fingers, showing that the tumor 
was a spina bifida, containing a considerable amount of adipose and 
granulation tissue. The congenital deficiency in the spinal column, and 
consequent injury of the spinal cord, had produced incontinence of both 
urine and feces. 

6. We have already, in speaking of the distribution of the pudic 
nerve, alluded to the fact that enuresis in children is not infrequently 
produced through reflex action by disease or an abnormal condition 
external to the bladder, in parts which receive their nerves from the 
same source as the bladder. Henoch says : " Occasionally congenital 
phimosis, stricture of the urethra, irritation of ascarides, fissure of the 
anus, onanism, or vulvitis can be detected, upon the removal of which 
the enuresis ceases." Trousseau relates the case of a young man of 
seventeen years, who from childhood had been in the habit of wetting 
his bed two or three times every night. After unsuccessful trial of 
belladonna, strychnia, and mastich, it occurred to Trousseau that the 
infirmity might be due to congenital phimosis, and accordingly Pro- 



814 DISEASES OF THE GENITO-URINARY ORGANS. 

fessor Jobert circumcised him. With the exception of three consecutive 
nights, he was entirely relieved of his enuresis during his subsequent 
stay of nine months in the hospital. In dispensary practice, in New 
York City, we find preputial adhesions, with the accumulation of 
smegma between the glans and foreskin, and more or less balanitis, a 
common cause of disturbed function of the bladder. The dvsuria and 
enuresis cease when the adhesions are divided by the probe, the smegma 
removed, and the preputial inflammation or irritation has abated. 

7. A psychical cause, to which Bartholow alludes. The patient 
dreams that he is in a convenient place for urination, the desire of 
which is impressed on his thoughts, and awakens to find that he has 
urinated in bed. Since the action of the bladder is largely under the 
control of the will, a strong will or determination — if the patient be not 
too sound a sleeper, does exercise a controlling action over the bladder, 
even during sleep. We sometimes observe this effect of will power in 
the fact that the patient breaks the habit of enuresis through a sense of 
shame, or by a determination to avoid the disgrace* Thus one writer 
mentions the case of a girl, in whom severe flogging by her mother put 
a stop to the habit, and patients sleeping away from home, as when 
visiting among friends, or at a boarding school, sometimes break the 
habit through an effort of the will. The sense of profound shame which 
the infirmity produces, thus enables certain patients to control the action 
of the bladder even in sleep. The state of the mind should, therefore, 
be considered as an element both in the causation and cure of the 
infirmity. 

8. Malformation of the bladder or its appendages. These are of 
various kinds. Some of them are of such a nature that cure of the 
enuresis is difficult or impossible. Thus, Thos. U. Madden, M.D., 
F.R.S.C.E., relates the case of a young lady, who had been treated by 
different physicians in various localities with belladonna, iron, vesication 
of sacrum, and the other usual remedies, without the least benefit. The 
dribbling of urine w r as constant day and night, so that she was debarred 
from schools, and ridiculed and avoided by her associates. She w r as 
placed under chloroform, and her bladder was found to have the power to 
retain a considerable amount of urine. Pursuing the examination, Dr. 
Madden found that the urine dribbled from a small orifice about half 
an inch above the meatus urinarius, and covered by rugae of the mucous 
membrane. A No. 1 catheter was introduced its entire length through 
the opening, so that, in the opinion of Dr. Madden, there was malpo- 
sition and elongation of the right ureter, which, instead of emptying into 
the bladder, discharged the secretion of the right kidney upon the vulva. 
In malformations like the above, as well as in ectopia vesicae, recto- 
vesical, or vesico-vaginal fistula, the result of abnormal foetal develop- 
ment, the urine obviously dribbles constantly, and from the moment of 
birth. In perpetual and life-long dribbling, a malformation or congen- 
ital defect is probably the cause. 

Prognosis. — The prognosis depends on the cause or causes of the 
enuresis. Most of the causes are of such a nature that they can be 
removed, and the majority of patients can therefore be cured by appro- 
priate remedies. Enuresis due to irritating properties in the urine, to 



TREATMENT. 815 

irritation or inflammation in the genital organs or rectum, and that due 
to exaggerated tonicity of the muscular coat of the bladder, can be for the 
most part readily cured by appropriate measures, while that resulting 
from structural' disease of the spinal cord, or from malformations in the 
urinary tract, is least amenable to treatment. 

It is the common belief that those epochs in life which produce a 
decided change in the individual, as puberty or marriage, are likely to 
effect a cure in cases previously obstinate. This opinion is to a certain 
extent founded on fact. The development of the sexual organs at 
puberty seems to render the bladder less irritable and more retentive in 
some patients. Cases are also related, as one by Trousseau, in which 
incontinence ceased with marriage and pregnancy. But treatment in 
the ordinary form of enuresis should not be deferred in the hope that 
time and physical changes will effect a cure, for this belief is likely to 
be illusory. 

Treatment — The physician asked to prescribe for a case of enuresis 
should carefully examine the patient in order to ascertain the cause. 
Since the most common cause is irritability of the bladder, whether 
inherent in the bladder itself, or imparted to it by the stimulating prop- 
erties of the urine, the urine should be rendered as bland and unirri- 
tating as possible. It should be made, so far as possible, as bland and 
unirritating as tepid water. This is best accomplished by rendering it 
neutral. Excessive acidity of the urine, so common a cause of enuresis, 
is promptly removed by the liquor potassae administered in doses of a 
few drops largely diluted. I have found it a safe and efficient remedy in 
the treatment of this infirmity when the bladder is unduly irritable. If, 
therefore, in the examination of a case we discover no cause of the 
incontinence, except an exaggerated contractile power of the bladder, 
and the urine is acid, from three to five drops of the liquor potassae 
should be given three or four times daily, in a wineglassful of gum- 
water, until litmus paper shows that the urine is neutral, and its neutral 
state should be maintained. 

In belladonna we possess an agent which diminishes the functional 
activity of the bladder when the latter is in excess. It diminishes the 
contractile power of the muscular fibres, and its use is, therefore, indi- 
cated in the class of cases which we are now considering. ' In this 
country the tincture of belladonna is more commonly employed than 
the extract, which is used in Europe, especially in Continental Europe, 
and if obtained from a good laboratory its action is as certain as that of 
the extract, while its dose can be better regulated. Five drops of the 
tincture may be given every evening, or, if the enuresis be diurnal as 
well as nocturnal, every morning and evening, to a child of five years, 
and the dose be increased by one drop every second day if improvement 
do not occur, and physiological effects are not produced, until the dose 
is doubled, or even trebled. If the enuresis be relieved, or if, without 
its relief, physiological effects be observed, as dryness of the fauces, 
cutaneous efflorescence, or dilatation of the pupils, the dose should not 
be increased. When belladonna produces the desired effect it is no 
doubt best to continue its use for some weeks in the dose which is found 
to be effectual, and then to diminish the number of drops gradually. 



816 DISEASES OF THE GENITO-URIN ART ORGANS. 

Trousseau, who, as we have seen, considered enuresis in most cases 
a neurosis, highly extolled the treatment by belladonna, believing it the 
most effectual of all methods of cure. He prescribed the extract of bel- 
ladonna, gr. -f, or the sulphate of atropia, gr. t Jq-, but he did not state 
the age of his patients. The dose was increased, if necessary, and 
whatever dose he found to give relief was administered once daily for 
three, four, or five months, after which it was gradually diminished, 
but it was not discontinued until after the lapse of two to ten months. 
By this treatment, Trousseau states that a majority of his cases were 
signally benefited, and not a few entirely relieved. The following case, 
which recently occurred in my practice, indicates the mode of treatment 
in enuresis when it results from the cause wdiich we are now consid- 
ering: L.,aged eleven years, male, had diurnal and nocturnal enuresis, 
which seriously interfered with his comfort, and rendered him an 
object of aversion and ridicule among his schoolmates. He had pre- 
viously taken belladonna and other remedies without improvement. 
His urine was found highly acid. Five drops of liquor potassae were 
ordered to be given three or four times daily, and the tincture of bella- 
donna, to which he was accustomed, was administered in nine drop 
doses, three times daily, to be increased, if need be, to fourteen or fif- 
teen drops. The liquor potassse, in the dose mentioned, immediately 
rendered the urine neutral, and the enuresis from that time ceased. 
The treatment recommended above, of rendering the urine as little irri- 
tating as possible by neutralizing it, aided by belladonna, which dimin- 
ished the contractility of the muscular fibres, cured the infirmity, which 
had been most troublesome and tedious. 

If the enuresis be due to an abnormally large secretion of urine, the 
cause may be such that something can be done to relieve the patient. 
The liquid ingesta, in the latter part of the day, should be restricted. 
If it be found that the increased flow is due to diabetes or chronic 
nephritis, the enuresis, though an unpleasant symptom, is comparatively 
unimportant, and the grave disease which causes it requires chief atten- 
tion. The quantity of urine may be diminished in diabetes mellitus by 
the use of proper food, and in diabetes insipidus by ergot. 

Enuresis due to a vesical calculus is associated Avith symptoms, as we 
have stated above, which indicate the presence of the stone, such as pain- 
ful micturition, which may awaken the patient .at night, and thus pre- 
vent the accident of which we are treating. Urination more frequent 
and painful in the daytime than at night, occasional interruption in the 
stream of urine from the impediment, pus, perhaps blood, and an in- 
creased amount of mucus in the urine, indicate the presence of a stone. 
Fortunately, the calculus is easily detected by sounding, and by the 
present improved instruments it can be crushed and removed, or it can 
be removed by lithotomy, which, in the opinion of some, is less danger- 
ous, and is preferable to crushing, when the patient is a child. 

As we have stated above, the physician should always examine parts 
contiguous to the bladder, as the genital organs and rectum, in order to 
ascertain if there be any source of irritation in them which may pro- 
duce irritability of the bladder by reflex action. In some instances, as 
we have seen, enuresis rebellious to ordinary treatment ceases when 



TREATMENT. 817 

the irritation in parts contiguous to the bladder is removed. Phimosis, 
preputial adhesions, the accumulation of smegma between the foreskin 
and glans, with more or less balanitis produced by the foul products, 
anal fissure, vulvitis, or ascarides should, if present, receive treatment, 
and with the removal of the irritating cause the enuresis will probably 
cease. 

Cases in which preputial irritation produces an irritable state of the 
bladder are not infrequent among the poor of New York, whose habits 
are frequently degraded and filthy, and the treatment consists in dividing 
adhesions of the glans to the foreskin, cleaning away the smegma, and 
using a soothing ointment. The foreskin can, with few exceptions, be 
sufficiently stretched for this purpose, so that incision or circumcision, 
which is frequently performed in these cases, is unnecessary. 

If the enuresis be due to atony of the sphincter, a remedy is required 
which acts very differently from belladonna.. If weakness of the 
sphincter be the cause, the indication is obviously to increase its 
tonicity, and the two medicines which have been most successfully 
emploj^ed for this purpose are nux vomica, or its active principle, 
strychnia, and ergot. We have stated that the sphincter is more abun- 
dantly supplied with nerves than is the muscular coat of the bladder, 
so that those agents which restore innervation, and thereby increase 
muscular tonicity, act upon the sphincter more powerfully than upon 
the muscular coat. Ergot appears to exert a similar action, though, 
perhaps, less in degree, upon the sphincters of the bladder and anus, to 
that which it exerts upon the uterine muscular fibres. 

We can obtain a clearer idea of the effect of therapeutic agents upon 
paresis of the sphincter vesicae by observing their action in paresis of 
the sphincter ani, for these two sphincters suffer loss of power from the 
same causes, and recover it by the use of the same agents. 

In a very instructive paper on incontinence of feces, published by 
Dr. George B. Fowler, in the Amer. Journ. of Obstetrics, for October, 
1882, two cases are detailed, showing unmistakably the beneficial action 
of ergot in increasing the tonicity of the sphincter ani, and the same 
treatment is indicated for urinary incontinence when it arises from a 
similar cause. A child of seven years, in the practice of Dr. Fowler. 
had been closely confined to his studies, with probably some deteriora- 
tion of his health, when fecal incontinence commenced. The tonicity 
of the sphincter ani on examination with the finger did not seem much 
impaired. Nevertheless it was so increased by ten drop doses of the 
fluid extract of ergot that the incontinence was relieved. The second 
patient, an anaemic girl of thirteen years, had been under treatment 
with iron and other tonics without benefit to the fecal incontinence. 
Her flesh was flabby and surface cool, and, which is interesting to 
remark as throwing light on the condition of the vesical sphincter, 
when it lacks tonicity, a lack of resistance in the anal outlet was very 
apparent to the touch. A mixture, containing 15 minims of the fluid 
extract of ergot, and grain yj^ of strychnia, was given three times 
daily. At the end of the first week she had only two recurrences of 
the trouble, and in three weeks was cured. Four months afterwards, 
although she had been taking quinine and iron after the discontinuance 

52 



818 DISEASES OF THE GENITO-URTN ART ORGANS. 

of the ergot, a partial relapse occurred, and a suppository of five grains 
of ergotin, with butter of cocoa, was employed morning and evening. 
Immediate relief followed, the tonicity of the sphincter was restored, 
and the suppositories were discontinued after two weeks. The bene- 
ficial effects of ergotin in weakness of the sphincters is shown by these 
cases. Enuresis from weakness of the sphincter vesicae could not have 
been better treated than by the same remedies which relieved the fecal 
incontinence in these two patients. 

A considerable number of medicines have been employed with more 
or less success for enuresis, w r hich are now seldom used. According to 
Bouchut, M. Eibes was the first who prescribed nux vomica. The 
patient was a soldier, who had both urinary and fecal incontinence, and 
was cured of the weakness of the bladder in five days. Nux vomica is 
employed instead of strychnine, as its use involves less danger. Mon- 
diere prescribed this agent in combination with the black oxide of iron 
in the following formula : 

R .- -Extract! nucis vomicae gr. vj. 

Ferri oxidi magnetici gj. 

Ft. pil. No. xxiv. Take one pill three times daily. 

Although we accept the statement of Bouchut that strychnia is an 
"extremely dangerous" remedy for enuresis, if the patients be under 
the age of four or five years, yet over that age it can be safely pre- 
scribed as an adjuvant to the ergot in proper dose, and w T ith proper pre- 
cautions. A small dose, repeated after three hours, is obviously safer 
than a larger dose at longer intervals. 

Among the remedies not mentioned, which have been successfully 
employed in certain cases, the tincture of cantharides requires notice. 
In large doses, this drug causes strangury, but in small doses causes such 
irritation or stimulation of the surface of the urethra as to increase the 
contraction of the sphincter, and awaken the patient when the urine 
presses upon the urethral orifice, wdiich is rendered sensitive by this 
agent. Cantharides is an unpleasant remedy, and it is not much em- 
ployed of late years ; probably the benefit from its use is not usually 
permanent. A child of five years can take four or five drops, largely 
diluted with water, three times daily, and the dose should be gradually 
increased until there is some evidence of its effect on the outlet of the 
bladder. 

Cubebs, recommended by M. Dieters, the various vegetable tonics 
and astringents, iron, creasote, and many other remedies have fallen 
into disrepute, and are now seldom used. Sometimes certain combina- 
tions of remedies give prompt and entire relief. Eustace Smith says, 
" I have lately cured a little girl, aged four years, who had resisted all 
other treatment, with the following draught, given three times daily : 



R — Tinct. bellad. . 
Potas. bromidi . 
Infus. digitalis . 
Aquas 

Ft 



Zl- 

gr.x. 

ad gss. — Misce. 
haustus." 



The tincture of belladonna of the British Pharmacopoeia has about 
half the strength of that employed in the United States ; but, even with 



CALCULI, DYSUKIA, CR Y PTORCHI A. 819 

this allowance, I would not dare to prescribe so large a dose of this 
agent, except that smaller doses were first used, and tolerance of the 
remedy demonstrated. 

Local treatment has been attended by a degree of success. The neck 
of the bladder and the urethra have been cauterized by the nitrate of 
silver applied by the porte-caustique of Lallemand, with some relief of 
the enuresis, at least so long as the soreness remained. Baths and 
douches of cold water have also been used by many physicians, some 
of whom, as Underwood, Baudelocque, Guersant, and Dupuytren, state 
that they have obtained good results. This treatment is most beneficial 
in those cases in which the sphincter is relaxed. 

Finally, in certain patients the advice of Trousseau may be followed, 
that the patient in the daytime resist the inclination to pass urine so 
long as it does not greatly increase his or her discomfort; by this means 
greater tolerance of the presence of urine in the bladder is produced. 



Calculi, Dysuria, Cryptorchia. 

We have seen, in our remarks on uric acid infarctions, how calculi 
may form in the pelvis of the kidney, first as small concretions, and how, 
descending to the bladder they may become nuclei which gradually in- 
crease by accretions to their surfaces, or they may form primarily in 
the bladder. A vesical calculus is not very infrequent, even in the 
young child. Its presence is manifested by dysuria, and increase of 
mucus, and the occurrence of pus and sometimes of blood cells in the 
urine. Occasionally the flow of urine is obstructed by the presence of 
the calculus, and the consequent tenesmus causes prolapsus ani. Pro- 
lapsus ani and dysuria are important symptoms of stone in the bladder. 
Sometimes the bladder becomes greatly distended with urine, and there 
may be trickling of it, with oedema and soreness of the prepuce and ad- 
jacent parts. Now and then a calculus lodges in the urethra, producing 
more or less retention of urine, with oedema of the prepuce and adjacent 
parts. The treatment for calculus must be entirely surgical. Lithot- 
rity as now preformed with improved instruments, is devoid of danger 
and successful. If a stone lodge in the urethra, it is usually near its 
outer extremity where the canal is narrowest, and it can be removed by 
a pair of small forceps. 

Dysuria occurs from various causes. It not only results from a cal- 
culus, but also from urine concentrated and acid. We have stated 
above, that urine containing uric acid and the urates if they are abun- 
dant is highly irritating, and while this acid and its salts increase the 
frequency of micturition, they are likely to render it painful. They 
sometimes cause colicky pain from spasmodic contraction of the mus- 
cular fibres in the urinary tract, and even transient albuminuria has 
been noticed. Dysuria from this cause is best treated by alkaline and 
mucilaginous drinks. 

Dysuria not infrequently arises from a morbid state of the external 
genitals, and they should always be examined when micturition is pain- 
ful, or obstructed, to ascertain their condition. In the first two or three 



820 DISEASES OF THE GENI TO - U RT N A R Y ORGANS. 

years of life the prepuce is usually adherent to the glans through epi- 
dermal cells, which appear to arise from the rete Malpighii, and instead 
of becoming horny remain soft and filled with protoplasm. This ad- 
hesion is so common that it must be considered normal, especially as it 
does not give rise to symptoms. But occasionally, even in young boys, 
a pathological state sometimes occurs which gives rise to symptoms, 
among which is dysuria. Phimosis may be present, retarding the flow 
of urine, some of which is retained under the foreskin, where, decompos- 
ing, it excites balanitis, causes adhesions, and renders urination painful. 
Circumcision gives relief to the local disease and the dysuria. In the 
Outdoor Department at Bellevue Hospital, where a considerable number 
of cases of this kind have been brought for treatment, it has rarely been 
necessary to circumcise or slit the prepuce. Instead of this, the adhe- 
sions are divided by a probe, the prepuce stretched and drawn back so 
as to expose the glans, and the parts thoroughly smeared with a simple 
ointment; if there be much inflammation and swelling, it may be neces- 
sary to etherize the patient for the operation. 

In young girls the labia minora are often adherent, apparently 
through a catarrhal inflammation. They can, for the most part, be 
readily separated by traction, when minute drops of blood appear upon 
the exposed surfaces, showing that a vascular connection has already 
occurred. Henoch 1 says, " In a few cases this adhesion appears to me 
to be the cause of dysuria, which disappeared after the separation of the 
labia from one another; in others examination showed inflammatory red- 
ness of the introitus and meatus, with increased secretion of mucus, 
which renders the excretion of urine painful." Separating the adhe- 
rent parts and covering the surface with simple ointment to prevent 
readhesion, suffice to effect a cure of the dysuria when it depends upon 
this cause. 

In the first months of foetal life the testes lie in the abdominal cavity 
in front of and a little below the kidneys, behind the peritoneum, and 
attached to the base of the scrotum by a long cord, the gubernaculum 
testes. Between the fifth and sixth months the testes descend to the 
iliac fossa, with corresponding shortening of the gubernaculum. At 
the end of the eighth month it has descended into the scrotum sur- 
rounded by a pouch of the peritoneum, which becomes detached from the 
peritoneum "just before birth " (Gray), forming a closed sac, the 
tunica vaginalis. It is estimated that in one case in five, the descent 
of the testicle is delayed from a few months to a year after birth. 
Astley Cooper states that the descent does not occur in some cases until 
between the thirteenth and seventeenth year. When there is this late 
descent, intestine is apt to follow the testicle, causing inguinal hernia. 
In about one case in one thousand, it is estimated, the testicle does not 
descend, but remains in the abdominal cavity, either on account of ad- 
hesions to the abdominal viscera, the small size of the ring, or some 
defect in the gubernaculum. Occasionally, a retained testicle has the 
normal structure and development, but, as a rule, it is imperfect and 
small, like the testicle of the infant, and it is prone to fatty or fibrous 

1 Diseases of Children, Wood & Co., 1882. 



VULVITIS. 821 

degeneration. If both testicles are retained, impotence may result on 
account of the non-development or degeneration. No treatment is 
required for the retained testicle, unless it become inflamed when lying 
in the inguinal canal, when it should be treated by poultices and other 
soothing remedies. 

Vulvitis. 

Inflammation of the vulva is common in girls under the age of five 
years. Like most other inflammations, it varies in severity in different 
cases, from a mild and transient attack to one attended by tumefaction 
and excoriation or ulceration of the labia, pain, and abundant discharge. 
Ordinarily when the physician is consulted, the disease has continued a 
few days, and he finds the vulva moist from a muco-purulent discharge, 
which dries into light yellow crusts, and produces greenish or yellowish 
stains on the underclothes. The vulva and lower part of the vagina is 
sensitive and red, and the acrid secretions sometimes cause redness of 
the skin over which they flow. Frequently the labia are swollen and 
tender, the patient may complain of soreness from friction in walking, 
and sometimes dysuria occurs from extension of the inflammation into 
the urethra. In severe cases ulcerations or erosions upon the labia re- 
sult, increasing the distress of the patient. 

Vulvitis is sometimes aphthous. Small rounded elevations appear 
upon the vulva, and ulcerate, and the adjacent surface is red and more 
or less swollen. The ulcers are sensitive and painful, but under ordi- 
nary circumstances they progressively heal. Rarely, in those who are 
markedly cachectic, the ulcers become gangrenous, and recovery is 
tedious and uncertain. 

Etiology. — The most common cause of vulvitis appears to be un- 
cleanliness, and hence its frequency in the families of the poor and de- 
graded in cities. The collection of dirt and sebaceous matter upon 
the vulva, and the irritation to which it gives rise, which prompts the 
patient to rub or scratch the parts, cause inflammation. Perhaps 
among the causes we may mention "taking cold," which excites a 
vulvitis, as it sometimes does an otitis externa. Struma strongly pre- 
disposes to this inflammation, so that slight irritating causes develop it 
in those who possess this diathesis. A considerable proportion of those 
who have vulvitis, have or have had other manifestations of scrofula, 
and present the strumous aspect, so that it seems proper to consider 
the inflammation of the vulva occurring under such circumstances 
as possessing a strumous character, or as a local manifestation of the 
strumous diathesis. We therefore, with Dr. West, regard struma as an 
important predisposing cause of vulvitis in the child. Ascarides in 
the rectum have long been recognized as a cause, producing this effect 
by the intense itching which prompts the patient to rub the parts, and 
thereby inflame them. It is said that ascarides sometimes crawl to the 
vulva, and produce inflammation by their presence upon the sensitive 
surface. A last and most important cause is infection by gonorrhoeal 
pus. Every physician who sees cases in the dispensaries or tenement 
houses of our large cities, meets cases, even girls of three or four years, 



822 DISEASES OF THE G E XI TO - U RI N A R Y ORGANS. 

in whom the vulvitis has this cause. Sometimes the gonorrhoea is com 
municated criminally ; in other instances it is contracted from the in- 
fected seat of a privy, or from soiled towels or linen. A young man 
whom I attended, was under treatment for gonorrhoea, when his two 
nieces of about four and six years were infected by the same disease, 
probably from soiled towels. Neither the anatomical characters nor 
microscopic appearances have thus far enabled us to discriminate between 
gonorrhoeal and non-specific vulvitis, but it is not improbable that the 
differential diagnosis may yet be made by observing the gonorrhoeal 
microbe in the secretions of the one, and its absence from those of the 
other. In both forms of vulvitis, the muco-purulent secretion and the 
inflammatory lesions are identical. The danger of infecting the con- 
junctiva and producing purulent ophthalmia from inoculation with the 
secretion of vulvitis, is well known. On the other hand, it is believed 
by some that vulvitis is occasionally caused by inoculating the vulva 
with the mucopus of ophthalmia. 

Treatment. — The parts should be frequently bathed with tepid 
water or mucilaginous water, to insure complete cleanliness. This, with 
the use of a mild astringent employed with a syringe, suffices in most 
instances to produce immediate improvement, and in a few days to effect 
a cure. Vaginal injections of tannin or alum (5: 100), sulphate of zinc 
(2 : 100), or nitrate of silver (1 : 100), have been employed with good 
result in this disease. I have obtained benefit from the following mix- 
ture, and more frequently recommend it than any other : 

R — Zinci sulphat 9 SS - 

Plumbi acetat ^j. 

Tine, opii, 

Tine, catechu . . . . . . aa f ziij. 

Aquae . ad. f^iv. — ilisce. 

To be injected warm four or five times daily, through a small glass or 
gutta-percha syringe. The same should be applied with a camel-hair 
pencil to the external parts. The following are also useful formulae : 

R — Ext. opii aq. £j. 

Liq. plumbi subacetat. dil. . . . . f ^jv. — Misce. 

R — Pulv. zinci oxid. 

Acecti tannic 

Mucil. acacia? 

Aq. rossB 

If ascarides be present, a cold rectal enema of lime-water or salt and 
water, should be used daily. Benefit may be obtained from rectal 
enemas of simple cold water even when ascarides are not present. 




SECTION V. 

DISEASES OF THE CIRCULATORY SYSTEM. 



CHAPTER I. 

CYANOSIS. 

Certain of the diseases which pertain to the circulatory system have 
been treated of in other parts of this book (umbilical hemorrhage, gastro- 
intestinal hemorrhage, etc.). It remains to consider that general condi- 
tion of the blood which is designated morbus caeruleus, or cyanosis. 

In 1863, I read before the New York Academy of Medicine a statis- 
tical paper on cyanosis, which was published in the Transactions of that 
Society. This paper contains an analysis of 191 cases, collated from 
the various European and American medical journals, and to those 
cases I am indebted for most of the following facts pertaining to this 
disease. 

The term cyanosis or blue disease is differently employed by writers 
Some apply it to cases of transient lividity occurring in the course of 
acute diseases, as well as to those cases which depend on permanent 
structural changes, or on malformations. I apply this term, as do most 
pathologists, only to the latter cases. 

The propriety of considering cyanosis as. a distinct disease is apparent 
if we are not misled by the term which designates it. Lividity is not 
its most important or its essential characteristic. It is simply a sign, 
although conspicuous, and, indeed, the only one by which the disease 
can be readily recognized. Cyanosis is, in reality, a blood disease, its 
pathological state consisting in a deficient oxygenation of this fluid, or 
in an excess in it of carbonic acid, and probably of carbonaceous pro- 
ducts. It should be placed in the same category with leucocythsemia 
and melansemia. 

Statistics show that cyanosis is, with few exceptions, due to mal- 
formation in the circulatory system, and at the centre of circulation, 
namely, in the heart and in the large vessels which arise from this organ. 
In exceptional cases the cause of cyanosis is located in the lungs, when 
it is in all or nearly all instances either emphysema in both lungs, firm 
and thick fibrinous exudation over the lungs, compressing them by 
its contraction and causing, perhaps, carnification in parts of them, or 
the cause is compression of the lungs from caries of the vertebrae, and 
consequent depression of the ribs. These causes pertain to youth and 

(^823 ) 



824 CYANOSIS. 

manhood, rather than to infancy and . childhood. On account of this 
fact and the rarity of such cases, they need not be considered in this 
connection. 

Literature of Cyanosis. 

The ancient physicians, so far as can be ascertained from their writings 
still extant, were ignorant of cyanosis ; whether they overlooked it, or 
whether those early ages were exempt from it and the malformation on 
which it depends is peculiar to a posterity physically degenerate. The 
blue disease described by Hippocrates 1 was probably some acute febrile 
affection. Galen, whose voluminous writings, with an excellent index, 
are still extant, and whose comprehensive mind embraced the whole 
range of medical science of the second century, makes no mention of it, 
so far as I can find. In the Middle Ages, as appears from the remark 
of Boerhaave, 2 the common people believed the cyanotic to be the vic- 
tims of evil spirits ; and it is probable that physicians, during this long- 
period of superstition and intellectual lethargy, embraced the popular 
belief. 

On the revival of learning, pathological anatomy began to be more 
thoroughly and intelligently studied ; but it is evident that before the 
great discovery of Harvey, in the 17th century, it was impossible to 
refer cyanosis to its true cause. In the latter part of the century so 
favorably opened by Harvey's genius, malformations of the heart were 
observed and described by some pathologists on the continent, in cases 
in which cyanosis must have been present : but it is uncertain, from the 
brief records which they have left, whether any of them understood the 
dependence of this disease on the abnormal state of the heart. Boer- 
haave, in the beginning of the 18th century, attributes "a livid or black 
color diffused throughout the whole skin," evidently referring to cyano- 
sis, to "1, a relaxation of the vessels, while the vis a tergo remains the 
same, or, 2, to a too sudden increased pressure behind, without a relaxa- 
tion of the vessels." Vieussens, who was a contemporary of Boerhaave, 
and was more thorough in the examination of morbid as well as healthy 
structures, narrated the history of a cyanotic patient, with a description 
of the malformation, but the one who first gave particular attention to 
the blue disease was Morgagni. This Paduan professor, excelling his 
predecessors in thoroughness of observation and accuracy of deduction, 
published a theory in explanation of the disease which now, after the 
lapse of more than a century, has many adherents. In the same century 
with Morgagni, the 18th, but subsequently to his time, Drs. Pulteney, 
Wm. Hunter, Baillie, Wilson, and Abernethy in Great Britain, and 
Jurine and Sandifort on the continent, may be mentioned among those 
who contributed to a knowledge of cyanosis, by the publication of cases, 
with a description of the malformations. Yet, when the present century 
commenced, no monograph or dissertation had appeared on this disease ; 
and, notwithstanding the publication of cases from time to time, the pro- 

1 De Morbis, lib. ii. sec. v. page 485, Ed. de Foe's, 1621. 

2 Diseases of the Humors, Acad. Lect., \ 732. 



LITERATURE OF CYANOSIS. 825 

fession generally were almost totally unacquainted with its nature. No 
better idea can be given of the prevailing ignorance, in reference to 
cyanosis at this period, than by quoting from a case related by Ribes in 
1814. 1 The patient had some time previously received an injury, of the 
finger. " Many physicians of Amsterdam,'' says he, "were at different 
times consulted on the subject of this affection, no one of whom under- 
stood its true cause, its essential character. One considered it as par- 
taking of the nature of epilepsy, and caused by the irritation in the 
nervous system which the wound in the finger had produced. Others 
attributed it to the presence of intestinal worms. Some physicians pro- 
nounced it an injury of the liver and spleen. Many held it to be a 
scrobutic affection. One only believed it to be the result of an unknown 
organic disease." 

Since the commencement of the present century the blue disease has 
received a large share of attention. According to Forbes s Medical 
Biography, the first dissertation on this subject appeared in 1805, from 
the pen of Seiler, and from this time till 1832 no fewer than twenty- 
eight dissertations or monographs were published, either on cyanosis or 
on malformations which produce it or at least relate to it. In the list 
of writers are some of the most eminent names in the profession, as 
Louis and Bouillaud. The number who have written on this subject 
since 1852 probably exceeds the number of previous writers. Of those 
who have contributed most to our knowledge of the disease may be men- 
tioned Farre, Chevers, and Peacock in Great Britain, Grintrac on the 
continent, and Moreton Stille in this country. Farre, Chevers, and 
Peacock wrote on malformations of the heart, alluding incidentally to 
cyanosis, but their writings contain valuable matter for statistics bearing 
on the latter subject. Farre's book was published in 1814, and is out 
of print ; Chevers published his papers in the London Med. Gf-azette, 
commencing in the year 1845 and running through several successive 
volumes. Peacock's treatise was published in 1858. It contains 
several original cases, previously narrated by him to the London 
Pathological Society. The paper by Moreton Stille, 2 which has at- 
tracted much attention, especially in Europe, was his inaugural thesis. 

This paper relates entirely, in the words of the author, to " the laws 
of the causation of cyanosis." The only really complete statistical 
paper on the blue disease is that by M. Grintrac, published in 1824, in 
Paris, and embracing all the cases which had been accurately reported 
up to that time, namely, fifty-three. He, indeed, exhausted the subject 
for the period in which he wrote, but on account of the accumulation of 
material since, his monograph now seems incomplete. 

Two theories in explanation of the occurrence of cyanosis have divided 
the profession : the one attributing it to obstruction at the centre of cir- 
culation, and consequent venous congestion ; the other, to admixture of 
venous and arterial blood through openings in the septa of the heart, or 
through the ductus arteriosus. The former of these theories originated 
with Morgagni more than one hundred years ago, and is essentially the 
same as that advocated by Stille. Stille errs in placing Morgagni among 

1 Bull, de la Fac. de Med., 1815. 2 Amer. Med. Jour, of Med. Sci., 1844. 



826 CYANOSIS. 

the advocates of the other system. The second theory, or that which 
attributes cyanosis to admixture of venous and arterial blood, is said by 
Dr. Peacock to have originated with Hunter, but its ablest supporter 
was Gintrac. Of late, there are some pathologists who do not believe 
either theory is sufficient to explain the cause of cyanosis, but that the 
true explanation lies somewhere between the two. Among the most 
conspicuous of these is Prof. Walshe, of London. These theories will 
be considered in the proper places. 

Sex. — Writers on cyanosis state that there is a preponderance of 
males to females affected with it. Aberle, of Vienna, says that two- 
thirds were males in an aggregate of 180 cases which he collated. In 
Gintrac' s cases, 28 were males, and 16 females ; in Stille's, 41 were 
males and 31 females. The sex is recorded in 134 of the cases collected 
by me, of which 78 were males, 5Q females ; and if those cases are ex- 
cluded in which cyanosis was due to obstruction at the mouth of the 
pulmonary artery, the number of the two sexes is the same. In the five 
years commencing with 1858, according to the mortuary returns, 207 
died in this city from cyanosis, of which number 117 were males, 90 
females. In England, for two years, 418 males died of cyanosis, and 
273 females. Although statistics of different cities and countries agree 
in the fact of an excess of males over females, there does not appear to 
be that great preponderance of males which the earlier writers on this 
disease believed to exist. 

Causes of the Malformations. — Mothers sometimes attribute the 
malformations, and probably correctly, to strong mental impressions felt 
during utero-gestation. The mother of a patient treated by Dr. Pea- 
cock 1 stated that " two months before her confinement, she was fright- 
ened by seeing a child killed, and never recovered from the shock she 
sustained. In another case "the mother was much out of health, and 
stated that, when pregnant with the child, she was greatly alarmed by 
seeing a man who was dying of asthma." 2 In another instance the 
mother was frightened at the fifth month of pregnancy ; 3 and in still 
another case, recorded by Dr. Peacock, the mother, four or five months 
before her confinement, " was greatly alarmed by her husband, who 
was insane, standing over her for two hours with a loaded pistol." 4 

Occasionally the malformation appears to be due to some vice or 
taint in the system of one or both parents. In a case quoted from 
another continental journal 5 it is stated that "the mother, who had 
formerly suffered from rickets, gave birth to five children, all of whom 
died immediately or shortly after birth with symptoms of cyanosis. 
The father died at the age of thirty-six, of phthisis." Dr. Peacock 
relates a case in which the father was livid, and had the "pigeon- 
breast" common in the cyanotic. In the history of a patient, which 
was communicated by Cooper to Parre, it is related that " vices of con- 
formation of the heart appeared to have been inherent in the family. 
Of 12 infants only 4 survived, and more presented signs of heart dis- 



1 Malf. of Heart, p. 37. 


2 Op. cit., page 57. 


3 Op. cit., page 41. 


4 Op. cit., page 43. 


5 Gazette Medicale, for December 28, 1850. 





TIME OF COMMENCEMENT. 821 

ease." Dr. Buchanan relates the history of a child which was the 
second that had suffered and died in the same family in the same way. 
A patient treated by Mr. Leonard was the sixth child of a family, who 
had died at about the same age, with symptoms of cyanosis. Such 
instances are, however, exceptional. Ordinarily, the cyanotic have not 
only healthy parents, but healthy brothers and sisters. 

A patient whose history is given by Dr. William Hunter was born at 
the eighth month, but in nearly all other cases the full period of intra- 
uterine existence was reached. 

The opinion was expressed by Gintrac that the number affected with 
cyanosis to the entire population, varies in different countries. It is 
probable that the occurrence of the blue disease is not greatly, if at all, 
influenced by the nationality, but it is certainly dependent, to a con- 
siderable extent, on the condition of society. It is less frequent in a 
community in comfortable circumstances, and engaged in wholesome 
and quiet occupations. Pure air and outdoor exercise, plain., nutritious 
diet, freedom from cares and anxieties — in fine, causes which promote 
the physical well-being, diminish the liability to an ill-formed and cya- 
notic offspring. And, conversely, impure air, improper and insufficient 
diet, grief, etc., increase the percentage of cyanotic cases. Hence, it is a 
rare disease in rural districts, and comparatively frequent in cities, espe- 
cially in a large city like New York, which contains a numerous indi- 
gent and careworn population, living from year to year in the midst of 
agencies which operate stealthily but certainly to enervate the system 
and undermine the health. 

These remarks are abundantly substantiated by statistics. In New 
York City for the six years ending with 1860, one death resulted from 
cyanosis to 436 deaths from all causes ; and in Brooklyn the proportion 
estimated for two years was about the same. On the other hand, in the 
State of Kentucky, which contains few large cities, and in the death 
reports of which cyanosis is included in the general term malformation, 
there was, during a period of five years, one death from malformation 
to 2469 from all causes. In the State of South Carolina, for three 
years, one death resulted from cyanosis to 5018 from all causes. In 
the State of Massachusetts, for two years, there was one death from 
cyanosis to 1136 from all causes, and two-thirds of the cyanotic cases 
occurred in the counties of Suffolk, Essex, and Worcester, which con- 
tain large cities. In London one death occurred from cyanosis to 755 
from all causes during a period of three years. On the other hand, in 
England, including the city of London, there was, for the ten years 
ending with 1857, one death from cyanosis to 1589 from all causes ; 
and in the rural districts of Monmouth and Wales only one death 
occurred from cyanosis to 5578 deaths from all causes during a period 
of two years. 

Time of Commencement. — It is an interesting and somewhat 
remarkable fact that cyanosis, though dependent on a malformation, 
does not always commence at birth, or, at least, that it does not exist in 
degree sufficient to produce the cyanotic hue till some time has elapsed 
after birth. In 138 of the cases of cyanosis which I have collected, the 
time at which lividity was first observed is stated as follows : In 97 it 



328 CYANOSIS. 

was within the first week, and generally within a few hours of birth. 
In the remaining 41 cases it commenced as follows : 

In 3 at 2 weeks In 6 from 2 years to 5 years 

" 1 " 3 " " 1 "5 " " 10 " 

" 2 " 1 month. " 6 » 10 " " 20 » 

" 7 from 1 to 2 months. " 1 " 20 " " 40 « 

" 5 " 2 " 6 " " 1 over 40 years. 

"5 " 6 " 12 » — 

" 3 " 1 year to 2 years. 41 

In these 41 cases, in which blueness did not occur till after the age 
of one week, if the patient were less than two years old when it com- 
menced there was frequently no obvious exciting cause, but above this 
age, with three exceptions, such a cause is known to have been present. 
It is interesting to observe how trivial the exciting cause frequently is, 
and equally interesting to note how long patients have enjoyed good 
health, not having the least lividity, although the anatomical vice, to 
which the final development of cyanosis was due, had existed from 
birth. 

Dr. Theophilus Thompson 1 relates the history of a lady, thirty-eight 
years old, who was well till an attack of Asiatic cholera, after which 
her health was permanently impaired. Two years before her death 
she passed through a course of fever, and from this time was cyanotic. 
Dr. Waters 2 relates a case in which cyanosis began at the age of six 
years in an attack of measles. In a case published by Mr. Napper, 3 
the child fell at the age of six months, and from this time had cyanosis. 
A female, whose history is given by Prof. Tommasini, of Bologna, and 
quoted by Bouillaud, became cyanotic at the age of twenty-five in con- 
sequence of difficult parturition. Mr. Stedman 4 relates a case, in which 
cyanosis began at the age of ten weeks in an attack of convulsions. 
Dr. John P. Harrison 5 published the history of a baker, twenty years 
old, in whom cyanosis began five years previously after great effort in 
carrying wood. Louis and Bouillaud quote from M. Caillot the case of 
a child, who became cyanotic at the age of two months in an attack of 
hooping-cough. Louis also narrates a case in which hooping-cough 
had the same effect at the age of twelve years. Bibes treated a child 
in whom the blue disease began at the age of three years from a severe 
contusion of the fingers. In a case related by Marx it commenced at 
the age of ten months from a blow r on the back, inflicted by the mother. 
Mr. Speer 6 gives the history of a female, who at the age of thirteen 
years was put in a place requiring considerable exertion, and from this 
time was cyanotic. A patient, whose case is related by Cherrier, fell 
into a deep ditch in the winter season, and immediately after had a low 
fever, from which the blue disease commenced. In a case published by 
Tacconus the exciting cause was believed to be fright, in consequence of 
a fall from a great height, and in another, related by Bouillaud, it was 

1 Medico-Chir. Trans., vol. xxv. 

2 Philadelphia Medical Examiner, June, 1850. 

3 London Medical Gazette, 1841. * London Lancet, 1842. 

5 American Journal of Medical Sciences, 1847. 

6 Medical Times and Gazette, for 1855. 



SYMPTOMS. 829 

a blow received on the epigastrium after the patient had passed the age 
of fifty years. Similar cases are related by Mayo and Peacock. 

It will be seen that the exciting cause of cyanosis is usually such as 
produces a profound impression on the system, and affects the action of 
the heart. Precisely in what way it operates to develop the disease has 
not been satisfactorily explained. Mr. Mayo conjectures, that in the 
case related by him there was previously some compensation which 
ceased, or became inadequate in consequence of some change produced 
in the economy. Although cyanosis may not appear for months or even 
years, there is rarely improvement when it is once established. Appear- 
ances of amendment are deceptive. The disease when not stationary is 
progressive, and this explains the fact that few survive the middle period 
of life. 

Symptoms. — The symptoms in cyanosis vary in intensity in different 
patients, and in the same patient at different times, being milder if he be 
quiet and the mind calm, more severe if active, or if the mind be agitated. 
In mild cases, in a state of rest, they nearly or quite disappear, so that 
a stranger would not suspect that there was any serious ailment. They 
are aggravated by any cause which accelerates the action of the heart. 
In some patients, cyanosis is increased by the most trivial disturbing 
influences, among which may be mentioned nursing, dentition, crying, 
coughing and slight emotions of iov, sorrow, or anger. In more than 
one case it has been perceptibly increased by the stimulus of digestion, 
the color being deeper after a full meal than before. 

The cyanotic hue varies in different individuals from duskiness to a 
deep purple, almost black color. It is usually most marked in the vis- 
age, especially the palpebrse, cheeks, nose, and lips, in the ears, fingers, 
and toes, and upon the mucous surfaces. It is sometimes, without any 
assignable cause, confined to a portion of the body. In a case related 
by Mr. Steel, 1 the upper part of the body was livid and cedematous, and 
the lower part pallid and shrunken, and yet the malformation was of 
the kind which is commonly present in cyanosis. In the London 
Medical Times, March 8, 1845, copied from the Gf-azette 3£ediccde, is 
the history of a child six years old, in whom the color was deeper on the 
right than left side. There had been, however, hemiplegia of this side 
in infancy, but this had entirely passed off. On the other hand, in a 
case of rare malformation communicated by Cooper to Farre, in which 
the upper part of the system was supplied chiefly by arterial and the 
lower by venous blood, the discoloration was general. In exceptional 
instances livid maculoe, like those of purpura, have been observed upon 
the skin. 

Those affected with cyanosis have generally at birth been well formed 
and of the usual size, and in most cases, for a considerable period after 
birth, the appetite is good, bowels regular, and the system well nour- 
ished. But when cyanosis becomes so severe, as it does sooner or later, 
that its symptoms are rarely absent, digestion is imperfectly performed, 
and the body becomes either emaciated or stunted and puny. It may be 
stated, as a rule, that nutrition is in inverse proportion to the gravity of 

1 London Lancet, 1838. 



830 CYANOSIS. 

cyanosis. In thirty-three out of forty-one cases, in which the condition 
of the system, as regards nutrition, was recorded either a short time 
previously to death or at the autopsy, the body was either considerably 
emaciated or else diminutive, and those who were well nourished were 
usually such as had died early, or of some intercurrent disease. 

In this connection may be mentioned two abnormalities which have 
been observed in the cyanotic. The chest is often flattened laterally, 
with a projecting sternum, so as to present an appearance generally 
described in the records as "pigeon-breasted." Sometimes the most 
prominent part is directly over the heart, and in one or two cases the 
sternum was observed to be deflected toward the left. In the majority 
of the records, however, no mention is made of the external appearance 
of the chest. 

The other abnormality is frequently observed in chronic diseases of 
the heart and lungs, in which there is sluggish circulation and conse- 
quent altered nutrition in the fingers and toes. In twenty-eight cases 
it is stated that the tips of the fingers or toes, or both, were bulbous. 
This hypertrophy, if slight, is likely to be overlooked, and that it was 
observed and recorded in so many cases renders it probable that it was 
present in a much larger number. In one case the anatomical char- 
acter of this enlargement was examined, and was found to consist chiefly 
of hypertrophied connective tissue. 

The nails are often incurvated over the deformity. At a meeting of 
the Lond. Path. Soc, in 1859, Mr. Ogle narrated the history of a 
laborer, fifty years old, who had swelling, numbness, and lividity of the 
left arm, from pressure of an aneurism, and the fingers on this side 
were clubbed as in cyanosis. A patient whose history is related in the 
Glasgow Medical Journal, and who was believed to be cyanotic in con- 
sequence of a highly emphysematous state of the lungs, had a similar 
development of the tips of both fingers and toes. 

An interesting feature in cyanosis is the low grade of animal heat. 
The temperature of the body is in all cases below that of health. This 
is especially noticeable in the extremities. There has not been a suffi- 
cient number of accurate thermometric observations to determine whether 
the internal heat is usually reduced. The following only have been re- 
corded: Mr. Fletcher 1 relates the history of a young man, in whom the 
thermometer placed in the mouth did not rise above 80° Fahrenheit. 
Hodgson reports the case of a man, twenty-five years old, in whom the 
thermometer placed under the tongue rose to 100°, while in his own 
case it was two or three degrees below that term. In an experiment, 
recorded by Nasse, the instrument placed in the mouth fell little if at 
all below the healthy standard ; applied to external parts, it stood at 
about 21° Reaumur. 

The lack of heat is the source of great discomfort to a cyanotic 
patient. In mild weather he requires a fire to keep him warm, or an 
amount of clothing which to others would be intolerable, and in cold 
weather slight exposure strikes him with a chill. Nor can he increase 
his heat by active exercise, since his infirmity disqualifies him for this. 

1 Medico-Chir. Tran., vol. xxv. 



SYMPTOMS. 831 

Although the temperature of the surface is so low, the occurrence of 
perspiration, sometimes profuse, is mentioned in several of the records. 

In severe cases of cyanosis the generative system is imperfectly de- 
veloped. In the female, menstruation is scanty or delayed, and in the 
male signs of puberty are feebly manifest. If the disease be so mild 
that the symptoms are absent when the patient is in a state of repose, 
these organs attain nearly or quite their normal development. The 
catamenia have appeared as early as the age of sixteen years ; and a 
cyanotic patient treated by Cherrier had two children, but they both 
died of scrofulous affections. 

The action of the heart is necessarily much involved. In mild forms 
of the disease, if the patient be quiet, this organ may beat with consid- 
erable slowness and regularity, but in all cases exercise or excitement, 
which in a state of health would scarcely have any appreciable affect on 
the pulse, embarrasses its movements, and produces palpitation. In 
severe cases palpitation is rarely absent, and the pulse is frequent, feeble, 
and often intermittent. In a large proportion of patients bruits are pro- 
duced by the irregular circulation through the heart. 

The respiration corresponds with the action of the heart. It is accel- 
erated in proportion to the frequency of the pulse. The suffering in 
this disease is largely due to paroxysms of palpitation and dyspnoea. 
These occur sometimes without any apparent exciting cause, and when 
the patient is quiet, but they are commonly induced by those causes 
which we have already mentioned as aggravating the symptoms of 
cyanosis. They come on suddenly, and are attended by increase of 
lividity, distention of the jugulars, and sometimes of the cutaneous 
veins, and by a sensation of present suffocation. They last only a few 
minutes, and are succeeded by great depression of the vital powers. In 
infants, on account of greater nervous irritability, and feeble power of 
endurance, these paroxysms often end in convulsions, which occasionally 
are fatal. A cough is sometimes present, but is usually slight. 

Pain is not a common symptom. Some of the patients complain occa- 
sionally of headache, with or without vertigo, and occasionally also of 
pain in the chest, but it is uncertain to what extent or whether these 
symptoms are dependent on the cyanotic disease. The secretions do 
not appear to be affected, so far as has been ascertained. The same 
may be said of the intellectual and moral faculties. In a case related 
by Dr. Chevers, 1 the child was even said to be precocious. The mind 
is capable of steady application and acquisition, as in health, provided 
that the emotions are not unduly excited. 

Those who are affected with cyanosis are liable to various forms of 
hemorrhage, but this liability, if we may judge from recorded cases, is 
greater in youth and adult life than in infancy. In two cases blood was 
vomited, in one passed by stool, in one it escaped from the gums, in 
two from the mouth, in eight from the nostrils, and in sixteen it was 
expectorated. Pulmonary phthisis was, however, usually present in 
these last cases. An interesting case is related by Dr. Wm. M. Voris, 2 

1 Lond. Med. Gaz,, vol. xxxviii. 

2 Western Journal of Medicine for 1829. 



832 CYANOSIS. 

of a girl, nine years old, in whom hemorrhage occurred under the scalp, 
producing great tumefaction, and nearly closing the eyelids. An in- 
cision was made, from which a pint and a half of dark blood escaped, 
and it was estimated that more than half a gallon was lost during the 
ensuing two weeks, at the expiration of which time the incision closed. 
The patient recovered from the hemorrhage, but not from the cyanosis. 

Toward the close of life more or less anasarca occasionally occurs, 
especially around the ankles, sometimes in the eyelids and face, and 
rarely to a certain extent over the whole body. In certain patients it 
coexists with effusion in the serous cavities. 

It is evident that one who is affected with the severe form of cya- 
nosis is disqualified for the duties of active life. The sports of child- 
hood and the useful labors of mature years require an exertion for 
which he is physically unfit. He has not the ability even to engage in 
animated conversation, for he is overcome by emotions, whether of joy 
or sorrow. He lives almost an idle spectator of the world around him, 
prevented by his infirmity from engaging in its pursuits. 

Intercurrent diseases, especially those of childhood, are badly toler- 
ated ; but hooping-cough is the one which these patients are especi- 
ally ill-fitted to endure. Still, they sometimes pass safely, not only 
through hooping-cough, but through some of the most dangerous febrile 
diseases. It is a question of interest, but about which little is known 
with certainty, whether these intercurrent maladies are influenced by 
the cyanotic or venous condition of the blood. The symptoms of these 
maladies are no doubt more alarming, mainly on account of the embar- 
rassed action of the heart, and not on account of the state of the blood ; 
still it is' reasonable to suppose that malignant and asthenic diseases are 
rendered worse by the lack of oxygen, and excess of carbonic acid in 
the circulating fluid. 

Probably cyanosis does not furnish immunity from any other disease, 
although this statement has been made on a high authority. Roki- 
tansky says : " All forms of cyanosis, or rather all diseases of the heart, 
great vessels, and lungs, adapted to produce cyanosis, in a greater or 
less degree, cannot coexist with tuberculosis. Cyanosis affords a com- 
plete protection against it, and in this circumstance may be found an 
explanation of the immunity from tuberculosis which many conditions 
of the system, apparently very different in their character, afford." 1 
This opinion of the distinguished pathologist, notwithstanding his ample 
opportunities for observation and known accuracy as an observer, is not 
substantiated by statistics. So far from its being true, the low degree 
of vitality in cyanosis appears to favor the occurrence of tubercle. I 
have records of twenty-six cases of cyanosis in which tuberculosis was 
also present, in several of which the lungs contained cavities. This is 
about thirteen per cent, of the whole number in my collection — a large 
proportion, since so many die in early infancy, at which period the 
tubercular disease is not apt to occur. Cyanosis appears, also, to favor 
the development of cerebral diseases, especially congestion and coma, as 
will be seen presently. 

1 Hand, der Pathol. Anat., II. Bd. 



In 17 under the age of 1 week. 


" 10 from 


1 week to 1 month. 


« 12 " 


1 month to 3 months. 


« u u 


3 months to 6 months, 


<- 17 " 


6 " to 12 


u ]2 << 


1 year to 2 years. 


« 21 « 


2 years to 5 u 



MODE OF DEATH. 833 

Prognosis. — This is unfavorable. Most cyanotic individuals die 
young. The age which they attain has been made the subject of sta- 
tistical inquiry by Aberle. He states that in an aggregate of 159 cases, 
57, or 35 per cent., died before the end of the first year; 108, or more 
than two-thirds, died before the age of eleven years ; 30 between the 
ages of eleven and twenty-five years ; and of the remaining 21, only 5 
lived more than forty-five years. 

. The age at which death occurred, is given, in 186 of the cases col- 
lected by myself, as follows : 

In 21 from 5 years to 10 years. 

" 41 « 10 " " 20 " 

" 20 " 20 " " 40 " 

" 4 over 40 " 

186 



Sixty-seven, then, or more than one-third, died before the close of the 
first year ; 121, or more than three-fifths, before the age of ten years ; 
only 24 survived the age of twenty years, and 4 the age of forty 
years. Of course, the duration of life depends on the nature and extent 
of the malformations. Some of these are such as to render a speedy 
death inevitable. 

Mode of Death. — The mode of death is recorded in ninety-five 
cases, as follows : 

19 died in a paroxysm of dyspnoea. 

10 " suddenly (the exact manner not stated). 

14 " in convulsions (infants). 

2 " of apoplexy. 

7 " from hemorrhage. 

6 " of phthisis (though, as we have seen, twenty others had this disease). 

2 " of exhaustion, without hemorrhage. 

10 " of coma. 

2 " of abscesses in the brain. 

One died of each of the following diseases : cerebral irritation, con- 
gestion of brain, eifusion in the cranial cavity, acute hydrocephalus, 
paralysis from acute softening of the brain, dysentery, inflammation of 
heart, syncope, mucus in the air-passages, thoracic inflammation, chole- 
raic diarrhoea, pneumonitis, bronchitis, scarlet fever, croup. One died 
in trying to walk, one after a spasmodic cough in pertussis, one after a 
long agony, one after an agony of ten or eleven hours ; one is recorded 
to have died gradually, and three quietly. 

The ten who are stated to have died suddenly probably died in parox- 
ysms of palpitation and dyspnoea, which, we have seen, are easily excited, 
and of common occurrence in cyanosis. If so, this was the mode of 
death in 29 cases. Infants, with few exceptions, so far as appears from 
the records, died in convulsions. Nineteen died of cerebral affections, 
exclusive of convulsions, and in thirteen of these the cause of death was 
congestion, apoplexy, or coma. The hemorrhage of which seven died 
was probably, in most instances, dependent on phthisis, and six are said 
to have died directly of phthisis. We may, then, regard paroxysms of 

53 



834 CYANOSIS. 

palpitation and dyspnoea, convulsions, congestive affections of the brain, 
and phthisis, as common modes or causes of death in cyanosis. 

The malformations of the heart and great vessels which give rise to 
cyanosis are quite numerous. The following table exhibits their charac- 
ter and relative frequency : 

Cases. 

1. Pulmonary artery absent, rudimentary, impervious, or partially obstructed 97 

2. Right auriculo-ventricular orifice impervious or contracted . ... 5 

3. Orifice of the pulmonary artery, and the right auriculo-ventricular aperture 

impervious or contracted 6 

4. Right ventricle divided into two cavities by a supernumerary septum . .11 

5. One auricle and one ventricle ......... 12 

6. Two auricles and one ventricle 4 

7. A single auriculo-ventricular opening; interauricular and interventricular 

septa incomplete . . . . ... . . . .1 

8. Mitral orifice closed or contracted 3 

9. Aorta absent, rudimentary, impervious, or partially obstructed . . . -3 

10. Aortic and left auriculo-ventricular orifices impervious or contracted . . 1 

11. Aorta and pulmonary artery transposed 14 

12. The cava3 entering the left auricle ...... c . 1 

13. Pulmonary veins opening into the right auricle or into the cavae or azygos 

veins .............. 2 

14. Aorta impervious or contracted above its point of union with the ductus 

arteriosus , pulmonary artery wholly or in part supplying blood to the 
descending aorta through the ductus arteriosus 2 

Total 162 

From the above table it appears that in more than one-half of the 
cases of cyanosis the congenital vice which gives rise to it is located in the 
pulmonary artery. It is located also, in general, in that part of the 
artery which is nearest the heart. Its character is different in different 
cases. Sometimes there is an arrested development of this vessel, and 
in its place we find simply a ligamentous cord extending from the heart 
as far as the ductus arteriosus, while beyond this point the artery and 
its branches are pervious ; rarely the entire artery is ligamentous, and 
of course impervious; in other cases this vessel is open through its 
whole extent, but the part nearest the heart is so small as to be pro- 
perly considered rudimentary ; in others still, there is adhesion of the 
valves to each other as the chief congenital defect, and, finally, in rare 
instances the obstruction in the pulmonary artery is due to an adventi- 
tious membrane, which stretches across the vessel like a diaphragm. 
These last malformations, namely, adhesion of the valves and the for- 
mation of an adventitious membrane, are doubtless due to inflammation 
occurring in the artery before birth, and some attribute the arrested 
development and ligamentous state of the vessel to the same cause. 

In most cases of cyanosis, due to obstructive malformations, the in- 
terauricular and interventricular septa are more or less deficient. This 
deficiency obviously results from the obstruction, for the septa are formed 
in the heart after foetal circulation is established, and the blood, being 
prevented by the vicious formation from flowing in its proper channel, 
necessarily passes to the opposite side of the heart. More or less blood 
being forced from one auricle or one ventricle to the opposite cavity, it 
is evident that a permanent aperture must result in the septum. The 



MORBID ANATOMY. 835 

aperture in the septum ventriculorum is ordinarily at its base ; in the 
septum auriculorum it corresponds with the foramen ovale. 

In most of the obstructive malformations one and rarely two abnormal 
cardiac murmurs have been observed. The single murmur accompanies 
the ventricular contraction. As it has been observed in cases of com- 
plete as well as incomplete obstruction, it seems to be due mainly to the 
flow of blood through the apertures in the septa. 

Modes of Compensation. — In most cases of cyanosis the congenital 
defect is partially obviated by modes of compensation. In the most fre- 
quent malformation, that in which there is obstruction in the pulmo- 
nary artery, and a considerable part if not all the blood flows directly 
from the right to the left side of the heart, the ductus arteriosus not 
only remains open, but is greatly enlarged, through which a current 
of blood enters the pulmonary artery from the aorta, and passing to the 
lungs is oxygenated. The bronchial arteries have also been found 
greatly enlarged, and it is believed that though they are the nutrient 
arteries of the lungs, the blood which they convey to these organs is 
decarbonized in its circuit through them. In a case published by Mr. 
Le Grros Clark, 1 the bronchial arteries were not only enlarged, but a 
" branch from the internal mammary artery, which accompanied the 
phrenic nerve, was nearly equal in size to the parent trunk, and ex- 
pended itself principally in the adjacent adherent lung." Branches of 
the intercostal arteries have also been found enlarged, and entering the 
lungs, or connecting with vessels which enter the lungs. By such 
modes of compensation cyanosis is rendered milder, and life is pro- 
longed. To these we must attribute the fact that some have very con- 
siderable malformation, and yet do not become cyanotic. 

Morbid Anatomy. — This, as regards the circulatory system, has 
been sufficiently dwelt upon. No chemical analysis, so far as I am 
aware, has yet been made of cyanotic blood. We know that it is dark, 
its coagulability feeble, that it contains an excess of carbonic acid, and 
is deficient in oxygen. From the nature of cyanosis, it would be in- 
ferred that in many cases there is a degree of passive congestion in the 
cavities of the heart, and consequently in the capillaries of the general 
system, giving rise to more or less serous effusion. Statistics show that 
this is so. The quantity of pericardial fluid is in some patients in- 
creased. I have records relating to this fluid in fifty-one cases. Usually 
it was pure serum. In seventeen the quantity was half an ounce or 
less, if we include in the number those in which the amount is expressed 
in such terms as "due quantity," "usual amount," and "small amount." 
In twenty-four cases the pericardial fluid (serum) exceeded half an 
ounce, usually estimated at from one to six ounces, but in two it ex- 
ceeded the latter quantity. It one of the twenty-four this fluid was 
stained with blood. In two patients the records state that there was a 
small quantity of pure blood in the pericardium, and in one the two 
pericardial surfaces were agglutinated by inflammation. 

In some of the autopsies serum was found in the pleural cavities, 
usually in connection with pericardial eifusion, and in at least one in- 

1 Medico-Chir. Trans., vol. xxx. 



836 CYANOSIS. 

stance this fluid was tinged with blood. Old adhesions between the 
costal and pulmonary pleura were observed in a few instances. The 
condition of the lungs was recorded with more or less minuteness in one 
hundred and ten cases. Mention has already been made of the large 
number affected with tubercular disease, which was either confined to 
the lungs, or was chiefly exhibited in these organs. In thirty-five 
patients the records state that the lungs were of small size, either by 
compression, or sometimes, apparently, from the continuance of the foetal 
state over a greater or less portion of the organ. The compression was 
produced either by the distended pericardium or by effusion in the 
pleural cavities. In thirty-five cases the lungs presented a dark color. 
This hue in some specimens accompanied the unexpanded or foetal state 
of the organ, but in others there was the normal inflation, and the dark 
color was due to engorgement or congestion. In other cases the lungs 
are stated to have been natural, except the color. In nine emphysema 
was present in a part of the lungs, in two pneumonitis ; in two the color 
of the lungs was pale, in one a bright crimson ; in one the lungs were 
larger than natural, in one the right lung was absent, and in seventeen 
these organs were recorded healthy. 

I have records of the state of the liver in twenty-six cases, in sixteen 
of which it was enlarged, and in four of these it was congested. Con- 
gestion of the liver was present in eight other cases, in which no mention 
is made of its volume. The parenchyma of this organ had a natural 
appearance in nine cases, but in some of these there was enlargement. 
From these statistics it is probable that the liver is commonlv enlarged 
in cyanosis, and not infrequently congested. In a few cases the condi- 
tion of the other abdominal viscera is mentioned ; in some as healthy, in 
others as congested. Fifteen examinations of the brain were made, in 
seven of which congestion is recorded, and in three abscesses in the 
cerebral substance, in one of which cases the lateral ventricle was also 
filled with pus ; in two softening of a portion of the brain had occurred, 
in three the brain was firm or compact, in three the quantity of fluid in 
the cranial cavity exceeded the normal amount, and in one it was less 
than normal. 

Theories Relating to the Etiology of Cyanosis. — Although in 
nearly all cyanotic patients there are direct communications between the 
two sides of the heart, it is shown by many observations that these com- 
munications or apertures are not sufficient in themselves to produce 
cyanosis. This opinion w T as expressed half a century ago by Louis, who 
published an excellent monograph on the subject of these communica- 
tions, basing his remarks on an analysis of twenty cases. Since the 
publication of this paper, the belief has been pretty general in the pro- 
fession, and observations continue to substantiate it, that, although the 
apertures may be of considerable size, if the two sides of the heart, with 
their orifices and vessels, are in their normal state, so that they act 
symmetrically and without obstruction, cyanosis does not occur. In 
proof of the correctness of this opinion many cases might be cited of a 
pervious, and some of a largely dilated foramen ovale, without the 
cyanotic hue, cases which have been published in the journals since the 
appearance of Louis's monograph. Still, in cases of obstructive mal- 



ETIOLOGY OF CYANOSIS. 837 

formation, unless the obstruction be complete, cyanosis is more likely to 
occur in consequence of these apertures, for were they absent a larger 
amount of blood would be propelled through the narrowed orifice, and a 
larger amount consequently be oxygenated. 

Allusion has already been made to the two theories which prevail in 
the profession; oneattributing cyanosis to the intermingling of venous 
and arterial blood ; the other to obstruction at the centre of circula- 
tion, and consequent venous congestion. There are serious objections to 
the acceptance of either theory as an explanation for all cases. That ad- 
mixture of the two kinds of blood is not essential to the production of 
cyanosis, is apparent from the following facts. In one case in the Fourth 
Malformation, there was no communication between the two sides of the 
heart, and the ductus arteriosus was closed, so that admixture was im- 
possible. Again, in the Eleventh Malformation, or that in which the 
aorta and pulmonary artery are transposed, the blue disease evidently 
does not depend on the admixture of the two currents. On the other 
hand, in this curious state of the heart, the more the admixture the less 
the cyanosis, since the only way in which the systemic current of blood 
can be arterialized is by passing to the opposite side of the heart. An 
argument against this doctrine may also be found in the fact that the 
modes of compensation are not such as in any way diminish or obviate 
the admixture. It is admitted that in the more frequent malformations 
cyanosis is increased by the apertures, which allow the intermingling 
of the venous and arterial currents, but it is more reasonable to consider 
the intermingling and the cyanosis as the direct results of the malfor- 
mation, neither having precedence of the other, than to consider that 
they are related to each other as cause and effect, or as proximate and 
remote results. Viewed in this light, the admixture must be considered 
simply a concomitant of the cyanosis. 

The second theory, that of venous congestion, has numbered among 
its advocates many who have given special attention to the subject, as 
Morgagni, Louis, and Stille, but it seems to have even less claim for 
acceptance than the theory of admixture. It has been seen that in 
nearly all cases of cyanosis the two sides of the heart communicate freely, 
so that if the current of blood meet with an obstruction, as it commonly 
does, it readily escapes to the opposite side where the artery is large 
and gives it free passage. In this way congestion, if not prevented, is 
greatly diminished. Again, it will be seen that, although certain of the 
viscera are frequently found at the autopsy more or less congested, con- 
gestion is not uniformly present in the organs, as it would probably be 
were it the proximate cause in all cases of cyanosis. 

Moreover, in some patients the malformation is not obstructive. The 
cavities and their orifices are of the normal size, and cyanosis is due 
entirely to malposition of the vessels. It cannot be said that in these 
cases there is venous congestion from arrest at the centre of circulation. 
If there be any congestion, it must be due to the fact that venous blood 
does not circulate as readily as the arterial in the capillaries. It is true 
that in the paroxysms of dyspnoea there is sometimes more or less con- 
gestion; the distention of the jugulars shows this, but it subsides with 



838 CYANOSIS. 

the paroxysms, and it probably is no more than usually occurs when the 
respiration is greatly embarrassed. 

In fine, attempts to express the immediate pathological state pro- 
ducing cyanosis in the terms of a general law have failed. However 
plausible the above theories may appear in regard to certain cases, there 
are others to which they are manifestly inapplicable. Those who advo- 
cate these theories seem to lose sight of the obvious fact that the chief 
want of the economy in cyanosis is decarbonization of the blood, and it 
is hardly supposable that there can be any correct theory of its causa- 
tion which is not founded on this fact. With this physiological state in 
view, it does not seem difficult to express a theory in comprehensive 
terms which is applicable to all cases, such as the following : Cyanosis 
is due to vices or defects in the organism, usually congenital, which 
prevent the free and regular floiv of blood to, through, or from the lungs. 
So comprehensive a statement includes not only cases of malformation 
and malposition of the heart and its vessels, but also those few cases in 
which the lungs are in fault. In most patients, as we have seen, the 
current of blood toward the lungs is obstructed, and the current of blood 
from the lungs, in those comparatively rare cases in which the malfor- 
mation is on the left side. 

Treatment. — From the nature of cyanosis it is evident that the treat- 
ment should be more hygienic than medicinal. The patient should be 
warmly clad and kept in a warm room, and all agencies calculated to 
embarrass or disturb the functions of the body or excite the emotions, 
and thereby accelerate the heart's action, should be studiously avoided. 
The diet should be nutritious, but simple and easily digested. 

Those who have attributed cyanosis wholly to apertures in the inter- 
auricular and inter- ventricular septa, and the consequent flow of blood 
from the right to the left side of the heart, have considered it an impor- 
tant part of the treatment to keep the patient reclining on the right side, 
so as to diminish this flow by the effect of gravitation. The reader, 
however, must be convinced from the nature of the malformations that 
little benefit can accrue from following such advice. Still, patients are 
sometimes less cyanotic and more comfortable in one position than 
another. In a case reported by Mr. Howship, 1 "the only easy and 
indeed comfortable position in which the child could remain was that 
usual in nursing. When erect, the dusky color of the face and neck 
became a dark blue." In a case related by Mr. Spackman, 2 the patient 
was easiest on the hands and knees. Louis 3 reports a case in which the 
selected position was with the head elevated; TTra. Hunter, 4 a case in 
which the patient avoided paroxysms by lying on the left side. Struthers 
and King 5 each report a case in which the patients seemed most com- 
fortable while lying on the right side; while, on the other hand, Pro- 
fessor White, 6 of Buffalo, and Dr. Jas. Carson, 7 report cases in which 
position on the right side failed to produce any alleviation of symptoms. 
Other similar observations might be cited, but enough have been men- 

1 Edin. Med, Journ., 1813. 2 Lond. Med. Gaz., 1833. 

3 De la Commun. des Cav., etc. 4 Med. Obs. and Enq., vol. vi. 

6 Monthly Journ. of Med. Sci. 6 Buff. Med. Journ., 1855. 

7 AniPr. Journ. of Med. Sci., 1857. 



TREATMENT. 839 

tioned to show that no one position should be recommended for cyanotic 
patients. Some obtain most relief by lying on the back, others on the 
right side, others on the left, some when on the hands and knees, some 
when reclining on either side indifferently, while, finally, others suffer 
least when erect. 

There was a time when the paroxysms were treated by venesection, 
but depletion has long since been abandoned. Physicians now rely on 
stimulants, antispasmodics, friction to the chest, and mustard pediluvia, 
to relieve the urgent symptoms, although this treatment is but partially 
successful. It is probable that of all internal remedies digitalis is the 
most useful, from the fact that it is an efficient heart tonic, and more 
than any other medicine gives strength and equality to the heart beats. 
In cities, where oxygen gas can be procured for daily inhalation, it 
seems not improbable that the urgent symptoms may in some instances 
be partially relieved by the use of this agent. 



SECTION VI. 



SKIN DISEASES. 



CHAPTEE I. 

EKYTHEMATOUS DISEASES. 

Undee this head are included erythema, roseola, and urticaria. They 
consist in an active congestion, inflammatory it is believed, of the skin, 
which soon declines, with or without slight furfuraceous desquamation. 
The color of the affected cuticle is bright red in erythema, rosy in 
roseola, and pale red in urticaria. Febrile symptoms often precede for 
a few hours the occurrence of the eruption, and they abate as it appears, 

Erythema. 

The eruption of erythema occurs in patches of different sizes, the 
largest ordinarily not exceeding four or five inches in length, and most 
of them have considerably smaller dimensions, their margins being in 
some instances diffused, and in others circumscribed and well defined. 
The patches are slightly swollen from engorgement of the capillaries of 
the skin and slight serous effusion, and are accompanied by a sensation 
of heat and itching. 

Erythema is idiopathic or symptomatic. The idiopathic form is sub- 
divided into erythema simplex, intertrigo, and l^eve. Erythema sim- 
plex is produced by external agencies of an irritating nature, as heat, 
cold, friction, chemical and mechanical irritants, applied to the skin. A 
common example of this form of the disease is the efflorescence about 
the anus in cases of infantile diarrhoea due to acidity of the evacuations. 
Erythema intertrigo is produced by the friction of opposing surfaces of 
the skin, and it therefore occurs mainly in the folds of the neck, about 
the groins, and behind the ears. This inflammation is sometimes slight, 
disappearing in two or three days with proper treatment ; in other cases 
the epidermis becomes denuded, the surface is tender and moist, and 
even superficial excoriations occur. In severe cases the ulcers extend 
more deeply and give rise to considerable purulent discharge, the skin 
and even subcutaneous connective tissue being more or less infiltrated 
and indurated. The confinement of the perspiration, and the moisture, 
( 840 ) 



DIAGNOSIS. 841 

which is exuded between the folds of the skin, increase the inflammation. 
The effused liquid does not in ordinary cases stiffen linen, as in eczema. 
Erythema lseve is the name applied to the inflammatory hyperemia of 
the skin, which often occurs over oedematous parts. Its most common 
seat is about the ankles and upon the legs. In children it is most fre- 
quently observed in the oedema which results from scarlatinous nephritis 
and from heart disease. 

Symptomatic erythema, which results from a general or constitutional 
cause of a pyrexial character, has several subdivisions. The simplest 
and mildest form of it is erythema fugax, which comes and goes quickly. 
The erythema which occurs upon the features in acute meningitis is a 
typical example. It is common in various inflammatory and febrile 
affections. If the erythematous patch be circular, with normal skin in 
its centre, it is sometimes designated erythema circinatum, and, if the 
margin be well defined, marginatum. Erythema papulatum, tubercu- 
latum, and nodosum are applied to the same form of the disease, one or 
the other term being employed according to the stage or size of the 
eruption. In erythema papulatum the eruption begins as small red 
spots, which soon become papular, and attain a size varying from that 
of a pin's head to a split pea. It occurs especially on the neck, breast, 
arm, and back of the hand, and fades away, with a slight desquamation, 
in about three weeks. In erythema tuberculatum and nodosum the 
eruptions have a greater diameter, and are usually more prominent. In 
the latter variety they often have a diameter of two or more inches, and 
occur most frequently upon the anterior aspect of the leg. These three 
forms of erythema, which may be described as one, occur chiefly in 
young people. Erythema tuberculatum is most common in servants, 
especially those recently from the country. The tumefaction is due to 
the effusion of serum in the corium, and, when the eruption has con- 
siderable prominence, also in the subcutaneous connective tissue. The 
color is at first a bright red, then dark red or purple, and it fades away 
like the discoloration of a bruise as the eruption declines. Rheumatism 
is often and diarrhoea occasionally associated with these forms of ery- 
thema, and rheumatic pains are occasionally present, as well as more 
or less febrile movement. 

Prognosis. — This, as regards the erythema, is always good. An 
unfavorable result in any case is due to cachexia, or some coexisting 
disease. The duration of the milder cases is only a few hours, while 
cases of a more severe type, as erythema nodosum, last two or three 
weeks. 

Diagnosis. — The ordinary forms of erythema are distinguished from 
erysipelas, by the absence of any very decided burning pain, and tume- 
faction of the integument, and tendency to spread, and by less marked 
constitutional symptoms. In those cases of erythema in which there are 
infiltration and swelling of the skin and subcutaneous connective tissue^ 
the patches are distinguished from those of erysipelas by being multiple, 
of smaller size, less hot and painful, not extending, and presenting as 
they disappear the phenomena of a bruise. In urticaria the wheals 
that come and go suddenly with a peculiar stinging sensation, and the 
irritability of the skin in consequence of which these wheals are pro- 



842 E R Y T IT EMA. 

duced by slight friction, differ so much from the symptoms and appear- 
ances of erythema that the differential diagnosis of the two is easy. In 
roseola the eruption ordinarily occurs over a large part, if not the entire 
surface, in points and small patches with healthy skin between, and pre- 
senting a rosy instead of a bright red color, characters which sufficiently 
distinguish it from erythema. Erythema when extensive is sometimes 
mistaken for the scarlatinous eruption, but the redness of the fauces, 
graver constitutional symptoms, vomiting, persistence of the eruption, 
etc., serve to distinguish the latter from the former affection. In cases 
of doubt it is proper to defer the diagnosis for a day or two, when if the 
rash be erythematous it will fade. Erythema sometimes occurs in the 
initial stage of variola, when, on account of the grave general symptoms, 
it may be mistaken for scarlatina. I have more than once known this 
mistake to be made in the hurried visit of the physician. A more care- 
ful examination w r ould prevent this error. There is little danger of con- 
founding erythema with measles, or the various papular, vesicular, or 
pustular skin diseases. 

Treatment. — Erythema fugax requires no special treatment, unless 
occasional dusting the surface with lycopodium or powdered starch. 
Those forms of erythema which are due to mechanical or chemical irri- 
tants soon disappear when the cause is removed. In erythema around 
the anus, produced by the irritation of the urinary and alvine evacua- 
tions, the diaper should be changed as soon as soiled, and if the stools 
be frequent and acid, the alkaline treatment proper for the diarrhoea is 
useful also for the erythema. In inflammation from this cause as well 
as in erythema intertrigo, the following prescriptions for external use 
will be found beneficial : 

R. — Bismuthi subnitrat gj. 

Glyceriti amyli ....... ^j. — Misce. 

R. — Lycopodii ^ss. 

Pulv. bismuthi subnitratis .... ^ iss. — Misee. 

R.^Pulv. zinc, oxid., 

Lycopodii aa gj. — Misce. 

To be frequently dusted upon the inflamed surface. It is better to apply vaseline 
first, and dust upon this. 

R. — Zinci oxid. gij. 

Glycerine gij. 

Liq. plumb, subacetatis 3 iss. 

Aqua3 calcis gvjtoviij. — Misce. 

In obstinate cases a weak solution of nitrate of silver, sulphate of cop- 
per, or better, as it does not stain the linen, sulphate of zinc, will fre- 
quently be followed by immediate improvement. 

Be. — Zinci sulphat, gr. vj. 

Glycerinse . . . . . . . . 5ij. 

Aq. rosse 31V. — Misce. 

To be constantly applied between the folds of the skin on linen. 

Potassium chlorate, internally, to correct the acidity of the transpira- 
tion from the skin in protracted and obstinate cases, and in certain in- 
stances cod-liver oil and the syrup of iodide of iron, are called for. If 



ROSEOLA. 843 

the derangement of the system upon which the erythema depends appear 
to be of a rheumatic character, colchicum or alkalies may be required. 
Erythema papulatum, tuberculatum, and nodosum occur most frequently 
in reduced states of the system, and therefore need tonics. 



Roseola. 

The term roseola is applied to rose-colored spots or patches of greater 
or less extent, accompanied by a degree of febrile reaction, and often 
by redness, with little or no swelling of the faucial surface. It is at- 
tended by a sensation of warmth and slight itching. The following 
groups and subdivisions embrace the recognized varieties of this disease: 

Koseola. 



Idiopathic. 


Symptomatic. 


Infantilis. 


Variolosa. 


JEstiva. 


Vaccinia. 


Autumnalis. 


Miliaris. 


Annulata. 


Rheumatica. 


Punctata. 


Arthritica. 




Cholerica. 




Febris continue. 




Syphilitica. 



The color of the eruption gradually fades from a rose-red to a duller 
hue, and often disappears in two or three days. In other instances the 
eruption lasts a week or more. Roseola may occur in any season, but 
it is most common, especially the idiopathic form, in the warm months. 
Those varieties of the idiopathic disease which are designated infantilis, 
sestiva, and autumnalis are the most common in early life. They are in 
reality identical, or nearly so, and may be described as one disease. 

Symptoms. — Roseola infantilis, sestiva, or autumnalis may be partial, 
appearing upon the arms and legs, or general. It is often preceded by 
febrile movement, languor, and, in those old enough to describe their 
sensations, pain in head, back, and limbs. There is great difference, 
however, in different cases as regards the severity of the prodromic 
symptoms. They may be absent or so slight as scarcely to be appre- 
ciable. Occasionally vomiting, diarrhoea, or other symptoms of derange- 
ment of the digestive apparatus immediately precede the eruption. 

The eruption of roseola, when general, usually commences upon or 
about the neck and face, and in the course of twenty-four to thirty-six 
hours appears upon the rest of the surface. It bears considerable 
resemblance to that of measles. The patches are irregular in shape, a 
quarter to half an inch in diameter, and, though of a rose color at first, 
they soon present a dusky due as they begin to fade ; by pressure the 
redness disappears. In the majority of cases the eruption has nearly 
faded by the fifth day. The redness of the faucial surface, together 
with the itching or tingling, disappears with the subsidence of the rash. 

Roseola annulata is a rare disease. It commences with constitutional 
symptoms, which are slight or pretty severe, and which cease when 
the eruption appears, this occurs in the form of red circular spots, 



844 ROSEOLA. 

which enlarge to the diameter of an inch or thereabout and assume the 
shape of rings inclosing healthy skin. The rash fades in a few days, 
often leaving a bruised appearance. The ordinary location of this form 
of erythema is upon the abdomen, and about the thighs. In roseola 
punctata the eruption is of small size, and it occurs upon a large part 
of the surface. 

Symptomatic roseola, which appears in the course of various diseases, 
need only be alluded to. The diseases in which it is developed are, 
with the exception of syphilis, chiefly of an acute febrile or inflamma- 
tory character. This eruption is often really, as stated by Tilbury 
Fox, a rose-colored erythema, but in other instances it presents the 
typical form and appearance of roseola. Thus I have known it to occur 
about the eighth or ninth day of vaccinia in rose-colored spots over the 
whole surface, and producing much anxiety on the part of parents, lest 
impure virus had been employed. 

Causes. — These are in a measure obscure. The delicacy of the skin 
in infancy and the active cutaneous circulation no doubt predispose to 
reseola and erythema, and hence the frequency of their occurrence in 
acute febrile and inflammatory affections. Summer weather, with the 
derangements of system which it produces, has been in my experience 
much the most frequent cause of idiopathic roseola in young children in 
this city. In certain summers, as in that of 1868, a large proportion 
of the infants have been affected by it, and I have been led to consider 
it a favorable prognostic sign as regards the diarrhoeal affections which 
are so common in the warm months. 

Prognosis. — Roseola is always a mild and favorable disease. 

Diagnosis. — Roseola is distinguished from measles, by the absence 
of catarrhal symptoms, a less degree of fever, less uniformity in the size 
of the eruption, and the absence of any history of contagion. Roseola 
is distinguished from erythema by the smaller size of the eruption and 
its rosy or dusky red color. The boundary line, however, between the 
two diseases is not well defined, and certain forms of- roseola may be 
described as erythema. The general but punctiform efflorescence, 
increase of temperature, acceleration of pulse, and the peculiar appear- 
ance of the tongue and fauces, serve to distinguish scarlet fever from 
roseola. There is little danger of confounding roseola with urticaria, 
since the wheals of the latter appear ii»no other disease. 

Treatment. — This is simple. If roseola occur in connection with 
gastro-intestinal derangement or disease, the remedies which relieve the 
latter exert a curative effect upon the former. In all cases the state of 
the system should be inquired into, and any departure from a state of 
health corrected. Roseola needs no further constitutional treatment. 
If there be itching or tingling of the surface, a lukewarm lotion, con- 
taining equal parts of liq. amnion, acetat. and mistura camphorse, has 
been recommended, or a lotion containing a drachm of hydrocyanic 
acid to a pint of an emulsion of bitter almonds, used warm. The pur- 
pose of sjch lotions is simply to relieve the unpleasant sensation. Cold 
applications, or others which would repel the eruption, should be avoided ; 
such an effect might be injurious. In case of acidity of stomach alkaline 
remedies are useful, and in certain cases tonic treatment is indicated. 



URTICARIA. 84:1) 



Urticaria. 

The name by which this disease is designated is derived from the 
term urtica, the nettle, the sting of which produces this form of erup- 
tion. The eruption occurs suddenly in wheals or pomphi, attended by 
tingling and burning, and suddenly disappearing. Urticaria is often 
accompanied by no very decided general symptoms, but in other cases 
there are febrile movement, and lassitude, with perhaps epigastric pain 
and headache. The wheals may occur over the whole body, but more 
frequently are confined to a portion of it. Their shape may be round, 
oval, irregular, or band-like, and their length varies from a few lines to 
several inches. In one affected by urticaria the wheals can be readily 
produced by scratching or rubbing the surface. The eruption is thus 
clearly described by a recent writer: " At first a bright flush appears, 
the centre of this becomes slightly elevated, and pales, hence appears 
of lighter color; the tint may be rosy, but more generally it is whitish." 
The margin of the wheal, the diameter of which varies, always remains 
red. This eruption appears to be produced by active congestion of the 
cutaneous capillaries, some serous effusion, and spasm of the muscular 
fibres of the skin. The effusion of serum in certain localities is quite 
apparent from the oedema which occurs. The subsidence of the erup- 
tion is without desquamation. Urticaria is ordinarily an acute disease. 
It is sometimes chronic in the adult, but rarely so in children. Several 
varieties of it are described by dermatologists, according to the cause, 
appearance, and duration. 

Causes. — These are external and internal. Various irritants apart 
from the nettle applied to the surface produce the wheals, as the bites of 
certain insects and sometimes turpentine. The following are the prin- 
cipal internal causes, as summarized by Hillier : 1st, profound and 
sudden mental emotion ; 2d, certain articles of diet, as shell-fish, pork, 
sausage, cheese, etc.; 3d, certain medicinal substances, as copaiba, vale- 
rian, and turpentine ; 4th, intestinal worms, though it is probable that 
these seldom operate as a cause ; 5th, uterine ailments, as hysteria. 

Prognosis — Diagnosis. — The prognosis is good, though the chronic 
form is sometimes tedious and troublesome. The occurrence of the 
wheals and the possibility of producing them by friction serve to dis- 
tinguish this disease from all others. 

Treatment. — In urticaria due to recent ingesta of an irritating 
or indigestible character, an emetic of ipecacuanha is useful, followed 
by a saline, and better also alkaline aperient, as Rochelle salts. An 
aperient of this kind is useful ordinarily in acute cases, attended 
by febrile reaction. The diet for several days should be simple, and 
such as is readily digested, as fresh beef, bread, or other farinaceous food, 
and milk. Occasionally the wheals appear periodically, when a few doses 
of quinine effect a prompt cure. After the above measures have been 
employed, the subsequent treatment, whether tonic or otherwise, de- 
pends on the condition of the patient. Little benefit accrues from local 
measures. Sponging the surface with cool water to which a little vinegar 
is added relieves, in a measure, the heat and tingling of the wheals. 



&±ti PAPULAR DISEASES. 



CHAPTEE II. 

PAPULAR DISEASES. 
Strophulus. 

The three papulae, namely, lichen, prurigo, and strophulus, which 
are characterized by small and firm elevations upon the skin, occur in 
children ; but the two former are not common, and, as they' do not 
differ in any essential particular from the same diseases in the adult, 
they will not be treated of in this connection. Strophulus, on the other 
hand, is a disease peculiar to children. It is known as the red gum or 
white gum, according to its appearance, and also as the tooth rash. 
This eruption appears usually on parts which are exposed, as the face, 
neck, and extremities, the papules being in some patients of the size of, 
or even smaller than, a pin's head, while in other cases they are as large 
as a millet-seed. 

The varieties of strophulus described by dermatologists are : 

S. intertinctus. S. candidus. 

" confer tus. " volaticus. 

" albidus. " pruriginosus. 

The following are the characters of these varieties : S. intertinctus, 
papules bright red, and occurring chiefly upon the cheeks, forearm, and 
back of hand ; often inter tinctured with blushes of erythema ; it lasts 
from two to four weeks, and is most common in young infants. S. con- 
fertus, papules numerous, and closely aggregated, paler, continuing 
longer than in strophulus intertinctus, and likely to recur, appearing 
about the time of dentition, and most frequently upon the arm. Some- 
times certain of the patches become chronic, slowly disappearing, and 
leaving the skin rough and dry. S. volaticus appears usually upon the 
arms and cheeks in patches of about a dozen, fewer or more, papules, 
which soon disappear. These patches reappear at intervals for two or 
three weeks, and are attended by heat and itching, though not intense. 
S. albidus, so called, should really be placed among the diseases of the 
sebaceous glands, and described under another name. It appears in the 
form of small white elevations as large as a pin's head, commonly upon 
the face and neck, and produced by distention of the sebaceous glands 
with the secreted product. The term strophulus candidus is applied to 
large whitish papules, which appear upon the sides of the trunk, shoul- 
ders, and arms of infants of one year or thereabouts, and disappear in 
about one week. They are liable to be associated with the papules of 
strophulus confertus. S. pruriginosus is really a form of lichen, occur- 
ring chiefly above the age of one, and under that of eight or nine years. 
The papules, which are small and discrete, usually appear over a large 



ECZEMA. 847 

extent of surface, ordinarily upon the back, front of the chest, the face 
and arms, and, as they are scratched from the itching, minute dark 
points of blood collect and dry upon their apices. This form of stro- 
phulus is more protracted than the others, and, in consequence of the 
irritation produced by the scratching, pustules of ecthyma often occur 
among the papules. The apparent cause of strophulus pruriginosus is 
a mode of life which impoverishes and vitiates the blood, such as un- 
cleanliness, and residence in damp, dark, overheated, and overcrowded 
apartments. Atmospheric heat also operates as a cause of this form of 
strophulus, and it is not an infrequent disease in cities during summer 
months. 

The various eruptions included under the term strophulus have such 
different anatomical characters, that a proper classification would locate 
some of them in other groups of skin diseases. One form of it, as we 
have seen, is produced by distention of the sebaceous glands; in other, 
and the majority of cases, as appears from the recent observations of 
Mr. Fox, its seat is the sweat glands, and in others still the papillary 
layer of the skin, as in lichen, the papules being produced by an exu- 
dation. 

Treatment. — Personal cleanliness, with frequent change of linen, 
and daily ablution without the use of soap, should be enjoined. Local 
irritants, which might aggravate or cause the disease, should, so far as 
practicable, be removed. Alkalies in cases of acidity of the primce vice, 
and occasionally mild aperients, are required: the food should be bland, 
but nutritious, and if the child be nursing, it may be necessary to attend 
to the healh of the wet-nurse. Favorable hygienic conditions, impor- 
tant for the successful treatment of all forms of strophulus, are especially 
required in strophulus pruriginosus. Nutritious diet, fresh air, quinine, 
iron, cod-liver oil, etc., should be prescribed for those affected by it. 
The following formula is recommended for sponging the surface in cases 
of strophulus: 

R — Sodii carbonat J)j. 

Glycerin® % ij . 

Aq. rosaa . . . . . . . . gvj. — Misce 



CHAPTER III. 

ECZEMA. 

This is one of the most common maladies of the skin. It constituted 
one-third of Devergie's cases, and one-sixth of Hillier's. In the com- 
mencement of the eczematous eruption the skin presents a superficial 
redness, and upon this inflamed area numerous minute and closely ag- 
gregated papules, vesicles, or, more rarely, pustules, appear. These 
are very fragile, so that they soon rupture, the epidermis is broken and 



848 ECZEMA. 

destroyed, .and the surface is moistened by an effusion which appears to 
be serum, and cannot be distinguished from it by the microscope. This 
liquid when dry stiffens linen. As it dries thin crusts form, of a light 
yellow color upon most parts of the surface, but they are thicker, and of 
a deeper yellow color, upon the scalp than elsewhere. The crusts consist 
mainly of pus, epithelial cells, and granular matter. 

Anatomy. — Biesiadecki has described the formation of the eczema tous 
eruption. According to him, the papules are produced from the papillae, 
which increase in size by cell formation in their interior. The connec- 
tive-tissue corpuscles enlarge, and are unusually "rich in fluid," and 
their number increases. Under the microscope spindle-shaped corpus- 
cles are observed, filling the papillae, and extending up from them into 
the rete Malpighii, crowding apart the cells of this layer, and reaching 
and elevating the epidermis. The epithelial cells in the immediate 
vicinity of the papillae also become swollen. This cell-growth produces 
the eczematous papule. 

If the cell formation continues within a papilla, certain of the cells 
are ruptured, and as they are very moist a liquid is effused, which raises 
the epidermis over the summit of the papilla. This produces the ecze- 
matous vesicle. Occasionally pus mixes with this liquid, and the erup- 
tion is then vesico-pustular. 

In acute eczema the upper part of the true skin is infiltrated and 
swollen, while the lower part is commonly unaffected, except in the 
most severe cases. The older the eczema the greater the extent of the 
infiltration, so that in chronic eczema the whole thickness of the skin is 
more likely to be involved than in acute forms of the malady. The dis- 
charge of the eczematous surface is irritating, and healthy skin, with 
which it may come in contact, is often reddened by it and made eczema- 
tous, from its irritating effect. This eczema occurring upon a part of 
the surface which is in contact with an opposite surface of sound skin, 
commonly affects the latter, and, as Neumann has stated, a nurse, by 
carrying an infant having eczema upon its nates, may contract the 
same disease upon her arm, although there is no contagious principle in 
this malady. 

Etiology. — Eczema is often produced by irritating substances applied 
to the skin. Croton oil, certain soaps, the finger-nails in scratching, a 
hat, truss, or belt, by pressure may produce it. Those having a tender 
and delicate skin are more liable to it than others. The constitutional 
causes are often obscure. It is sometimes obviously due to indigestion, 
or a diet which disagrees, for we see it occur in nursing infants as a 
result of sickness of the mother. Anaemia and scrofula are occasional 
causes. Among the city poor eczema is common, and many of the 
children who have it are scrofulous, but a large proportion show no 
evidence of struma, and in the better classes of society a majority do 
not. 

Varieties — Symptoms — Course. — Eczema is sometimes designated 
according to its location as JE faciei, capitis, etc. Another designation, 
which has more scientific Value, is according to the form and stage of 
the eruption, by which we have the following recognized varieties, to 
wit: Eczema papulosum, vesiculosum, pustulosum, rubrum, impetigi- 



VARIETIES — SYMPTOMS —COURSE. 849 

nosum, and squamosum. A simpler and still more convenient classifi- 
cation is into eczema simplex, rubrum, impetiginosum, and squamosum. 

Eczma of the scalp is common in infancy, occurring as an eczema 
rubrum or impetiginosum. The eczematous exudation mingling with 
the secretion of the sebaceous glands, which are numerous upon the 
scalp, forms a thick yellow crust. It is likely to extend beyond the hairy 
portion to the forehead and around the ears. This extension aids in 
establishing the diagnosis between eczema and certain other cutaneous 
eruptions of the scalp. Eczeina of the external ear is sometimes primary, 
but in other instances it is consecutive to that of the scalp, and due to 
extension of the latter. Its common seat is in the angle behind the 
ear, and upon the lobe of the ear, whence it often extends along the 
auditory meatus, narrowing its calibre, and impairing the hearing tem- 
porarily, or even for years. Eczema upon the forehead commonly 
occurs in children from extension of the eruption from the scalp. The 
cheeks, lips, and chin are often also affected by eczema, which in this 
situation is commonly eczema rubrum, and is attended by redness, swell- 
ing, and troublesome itching. The swollen and red appearance with 
the crusts and marks produced by scratching often greatly disfigure the 
countenance. In children, when eczema occurs upon other parts, it is 
usually associated with that of the scalp, face, or ears — that in the latter 
situations being the most severe and obstinate. 

Eczema simplex is common in the summer months, being produced by 
the heat of the atmosphere, aided perhaps by other causes. The patient 
may appear well, or be somewhat indisposed, having febrile symptoms, 
and soon an erythematous patch of greater or less extent appears, upon 
which a cluster of the characteristic papules or vesicles soon occurs. 
These break, forming slight crusts, which are detached, and the eczema 
declines, or it may continue longer, with successive crops of the eruption. 

In eczema rubrum. since it is a more severe form of the disease, the 
febrile movement and the local symptoms are greater than in the preced- 
ing variety, and the eczematous patch presents the appearance of a more 
intense inflammation. The papules or vesicles are often so minute as 
to be with difficulty recognized. They are soon broken, when they 
form with the secretion and exudation from the surface yellowish or 
brownish-yellow scabs. The discharge is more irritating, as it is more 
abundant than in eczema simplex, and the adjacent skin is usually more 
inflamed from its contact. 

Eczema impetiginodes is common in young debilitated children, in 
whom, in consequence of the cachexia, inflammations, of whatever char- 
acter, are liable to be suppurative. This form of eczema presents at first 
the symptoms and features of eczema rubrum, but the transparent liquid 
of the vesicles soon becomes opaque, from the generation and admixture 
of pus-corpuscles. The crusts, which form from the rupture and desic- 
cation of the vesiculo-pustular eruptions, are thick and greenish-yellow, 
and in infants the sebaceous glands, which are involved in the inflam- 
mation, pour out an abundant secretion, increasing the thickness of the 
crusts. This form of eczema is most common in infancy, and its usual 
seat is upon the scalp. 

54 



850 ECZEMA. 

Diagnosis. — Eczema presents in different instances so different an 
appearance that it is not always readily diagnosticated. It will aid in 
its diagnosis to. recollect that it is in its nature a catarrh, affecting prima- 
rily and chiefly the upper portion of the derma and the Malpighian 
layer, and although it may now present a dry or scaly appearance 
(E. squamosum), yet its history will show that there has been a discharge 
or moisture. In a large proportion of cases, the physician is not able to 
detect papules or vesicles, since they are fragile and transient, breaking 
in the first thirty-six hours, and not reappearing. Still, when they are 
absent, we sometimes observe around the margin of the patch an appear- 
ance which indicates that they have been there. Their minuteness is 
occasionally such that they may escape notice, on a cursory inspection, 
when they are present and well defined. Acute eczema, affecting a con- 
siderable extent of surface, is often attended by febrile movement, and 
may be mistaken for one of the eruptive fevers, but the absence of cer- 
tain distinctive appearances which characterize these fevers, and the 
speedy appearance of the eruption and moisture, establish the diagnosis. 
Eczema can be readily diagnosticated from ordinary erythema, which is 
a superficial inflammation without moisture. The location of erythema 
intertrigo serves for its diagnosis, as it is evidently produced by the 
attrition of opposite surfaces of the skin. Moreover, it lacks the ele- 
vated papillae, and the discharge does not stiffen linen like that of 
eczema. Lichen, when acute, presents some resemblance to eczema, but 
it is dry and papular, the papules, though small, being detected by the 
finger as well as sight. The large and irregular phlyctenule, intense 
inflammation and oedema, and mode of extension of erysipelas ; large, 
scattered, and non-inflammatory vesicles of sudamina; scattered and 
acuminate vesicles, without surrounding inflammation, of scabies ; are 
so different from the eczematous eruption that the differential diagnosis 
from those diseases is readily made. Herpes circinatus can be distin- 
guished from eczema by its circular shape, larger size, and greater per- 
manence of the vesicles, and the delicate, branny scales, which consist 
rather of epithelial cells than the product of exudation as in eczema. 

Treatment. — Eczema should be cured as speedily as possible, since 
there is no danger that another disease will arise from the disappearance 
of the eruption, while, on the other hand, the restlessness and fretfulness, 
which the eruption often produces, may impair tlue general health, and 
the lymphatic glands receiving lymph from the eczematous patches may 
undergo hyperplasia and cheesy degeneration. Many cases can be 
cured by strictly local measures, while in others, as when there is a 
markedly strumous cachexia or other manifest aberration from the 
healthy standard, constitutional measures are important. 

Constitutional Treatment. — No one line of treatment is suitable for 
every patient. Among the city poor strumous cases are common, and 
cases also in which, without any pronounced diathetic state, the cause is 
apparently a reduced state of the system from innutritious diet and other 
antihygienic conditions. Such cases require better diet, and a mode of 
life more in accordance with sanitary requirements. On the other 
hand, I have observed cases of eczema which seemed to be produced or 
rendered more intractable by a plethoric state of the system, especially 



TREATMENT. 851 

in the nursing infant, when the milk of the mother or wetnurse was 
unusually rich or abundant. While, therefore, ill-nourished and 
weakly children require better regimen, with perhaps vegetable and 
ferruginous tonics, the plethoric require reducing treatment, though of 
a gentle kind. Their food should be plain and unstimulating. Indi- 
gestible articles, as pastries, cheese, and rich sauces, should be avoided, 
especially when symptoms of indigestion are present. Indigestion or 
other aberration of the system from the healthy standard, should be 
promptly corrected. Saline aperients are useful in cases of constipation 
and of a plethoric habit. The saline diuretics, as the acetate and citrate 
of potassium, are often beneficial in acute eczema with febrile symptoms, 
especially if the urine be rather scanty. The following formula is re- 
commended by Dr. A. R. Robinson : 

R. — Potassi acetatis ....... giss. 

Spts. ffitheris nitrosi . . . . . . ^ij. 

Syrupi aurantii ^vj. 

Aquae carui q.s. ad. ^iij. 

One teaspoonful three times daily to a child of one year. 

In acute as well as chronic eczema any departure from the healthy 
standard, whether in the digestive organs, the kidneys, or other part of 
the system, should be corrected so far as possible, since eczema is more 
readily cured when the functions of the internal organs are normally 
performed. 

Chronic eczema as well as acute often requires internal remedies, 
although they are of less importance than external measures. In 
anaemic cases, iron is indicated, and arsenic, which should not be used 
in acute and moist eczemas, often produces a very beneficial effect, espe- 
cially in dry eczemas, when accompanied by much infiltration. In 
many cases of chronic eczema the following prescription will be found 
useful : 

R. — Liq. potassaa arsenit. ...... fgj. 

Tine, ferri pomati. \ . _ f 

Tine, rhei vini J aarjv. 

Aq. menth. ........ f^iv. — Misce. 

Dose, one teaspoonful three times daily to a child of one to two years. 

External Treatment. Acute Eczema. — The external treatment should 
be different in different cases, according to the stage of the disease and 
the condition of the affected surface. In acute eczema, irritating and 
stimulating applications are inadmissible. Even the garments worn 
should be as little irritating as possible upon parts covered by the dress. 
It is even recommended that the patient lie in bed in severe general 
eczema, with a light covering of bedclothes. Water is usually too 
irritating for eczema, so that baths and washes should be interdicted. 
Ordinary soap should never be employed in the acute disease, as it is too 
irritating. When the use of water is necessary for purposes of cleanli- 
ness, bran water, or thin flaxseed tea, or other mucilaginous infusion 
should be used. In eczema intertrigo, so common upon the groin and 
nates of infants, cotton batting, or the absorbent cotton of the shops, 
dusted with the following finely triturated powder, should be constantly 



852 E OZEMA. 

applied, so as to come thoroughly in contact with the inflamed surfaces 
and separate them: boracic acid one part, salicylic acid one part, sub- 
nitrate of bismuth or oxide of zinc five parts. 

Pruritus. — Itching is a frequent and annoying symptom of eczema, 
and whatever curative applications may be made use of, something to 
relieve this symptom is often required. Camphor mixed with ointments 
or washes, relieves itching. A two per cent, solution of acetic acid, 
or a half to a two per cent, solution of aluminium acetate in water, 
also frequently gives relief. Carbolic acid is one of the most effectual 
agents to relieve pruritus. The following formula is essentially that 
recommended by Kaposi : 

R . — Acidi carbolici grammes xv. 

Spts. vini galhci . ..... f^ v. 

Tine, lavendul. ) __ f 

Eau de cologne / * ' ' ' ' • aat 3 v J- 

Glycerini . . gj. — Misce. 

Veiel says that even this small amount of glycerine is sometimes too 
stimulating to the surface, and, if so, it should be omitted. 

Curative Applications. — In the commencement of eczema papulosum 
or vesiculosum, common powdered starch, talc (magnesium silicate), 
semen lycopodii, or rice starch (amylum oryzas), is beneficial for dusting 
the part. The following formula is substantially that recommended by 
Kaposi : 

H- — Amyli orizae . ... ... . ^iij. 

Talc venet. J 

Flor. zinci, 'I aa -5J X- 

Pulv. irid. florent. J 

Misce. 

Camphor may be added to this to relieve itching, in the proportion 
of two per cent. 

Curative Applications. — For healing the eczema in its acute stage, 
the following ointments are the most useful: 

R . — Emplas. plumbi, ) -n, t 

Vaseline, } ...... Equal parts. 

Ung. zinci benzoat, either in full strength or reduced by mixture with 
vaseline. In full strength it is sometimes too irritating. Crusts should 
be removed by soaking them with oil, or by an emollient poultice, and 
some hours subsequently washing the surface with warm water. If the 
surface be moist, the powder, prepared according to the above formula, 
can often be advantageously used instead of the ointment. A convenient 
and effectual way of using the ointment is to spread it thickly on linen 
or lint, which is then bound down by gauze. In eczema facei, a mask 
may be made with openings for the nose, eyes, mouth, and ears, and 
bound down upon the surface. In that form of eczema in which the 
skin is red and desquamating, the milder ointments should be used, 
rubbed in three times daily. 

Chronic Eczema. — The crusts should be removed by strips of linen 
or gauze soaked with cold distilled water, and frequently applied, so that 
the water does not become warm, for warm water applications by their 
irritating action may produce eczema. An equal quantity of Goulard's 



ECZEMA. 858 

extract may be added to the water if the skin is irritable (Veiel). 
Oils are, however, in most instances, preferable to water for the removal 
of crusts. Cod-liver oil, mutton suet, or one of the mild ointments, as 
cold cream, should be thoroughly applied by a painter's stiff brush upon 
parts covered by hair, so as to break through the crusts. On smooth 
surfaces, an ointment, as simple cerate, should be thickly spread on 
surgeon's lint or flannel, and applied over the crusts, 'which will usually 
come away on the removal of the plaster. A mild soap, the alkali of 
which dissolves the epidermis, will remove those crusts which the above 
measures fail to clean off, as Sarg's liquid glycerine soap. Lately 
salicylic acid has come into use as a solvent of crusts. The following 
ointment rubbed in hourly, or applied thickly spread on surgeon's lint, 
in a few days renders the surface clean : 

R. — Acidi salicylic. ....... zj. 

Vaseline 3i ss - — Misce. 

The first indication has now been accomplished, that of denuding the 
surface of crusts. The next indication is to cure the disease. In 
order to heal the moist surface the best application in most cases is still 
the diachylon ointment, the emplastrum plumbi recommended above, or 
the zinc ointment, by which the moist eczema becomes squamous. If 
the surface is slow in healing, Sarg's liquid glycerine soap or the fol- 
lowing : 

R • — Saponis viridis 200. 

Spirit, rectific 100. 

Digestre filtre ; 

should be poured upon moist flannel rubbed in, and then removed with 
tepid water. After drying the parts the ointment should be reapplied. 
Occasionally, on parts to which the lead or zinc ointment cannot be 
conveniently applied, as upon the face, one part of tannin to ten or 
fifteen of vaseline or cold cream may be used instead. 

By the above treatment the moist surface usually becomes squamous. 
The eczematous patch is still hyperasmic, infiltrated, and desquamating, 
and additional measures are required to restore it to the normal state. 
Moderately stimulating applications are now required, and tar is the 
best agent for this purpose. Tar should never be applied in moist 
eczema. Its use should be reserved for the dry and desquamating 
eczema. 

The various tars, which have been used with success in eczema, are 
the pix liquida or pine-tar, the oleum fugi or beech-tar, the oleum rusci 
or birch-tar, and the oleum cadinum obtained from the juniperis oxy- 
cedrus. Tar penetrates all the layers of the skin, for when used exter- 
nally it has been found in the urine. In a few patients it is stated that its 
employment has been followed by rigors, fever, headache, and vomiting. 
If such symptoms arise, its use should of course be discontinued. The 
following formuloe may be employed: 

R. — Ung. picis liquidae 5j. 

Alcoholis . . . . . . . gij. — Misce. 

R. — Olei rusci vel. cadini . . . . . . f?j. 

Alcoholis ........ fgij-iij. — Misce. 

Use externally. 



854 



SCABIES. 



&. — Olei rusci vel. cadini 
Alcoholis "I 
Etheris / 



aa f ^ iss 



•Misce. 



Use externally. 



Tar is useful when the skin chaps, or is rough. In cases that are in a 
state of transition from the acute and moist to the chronic and squamous 
form of the disease,- the mixture of the tar ointment with the diachylon 
ointment often has a salutary effect. 



Scabies. 

The diseases of the skin previously considered are non-contagious. 
Scabies, on the other hand, is one of the most contagious diseases by 
contact. It is produced by an animal parasite, known as the itch-mite, 
or acarus scabiei. The inflammation is caused by the female only, 
which burrows, making for itself a canal, or cuniculus, in which its eggs 
are deposited. The male does not burrow, but conceals itself under the 
scales or crusts which result from the inflammation produced by its 
partner, or it burrows only sufficiently to produce a covering and shelter. 
From observations made by Eichstedt, Gudden, and others, the female 
has been found within half an hour after being placed upon the skin to 



Fig 37. 



Fig. 



Fig. 39. 





Fig. 40. 









Fig. 37. The itch animalcule, acarus scabiei, viewed upon the back, showing its figure and the arrange- 
ment of its spines and filaments. The female, which is somewhat larger than the male, has a length 
of l-80th to l-60th of an inch. 

Fig. 38. The foot and last joints of the leg of the itch animalcule 

Fig. 39 The male itch animalcule, viewed upon the under surface, showing its legs and lobulated 
feet. 

Fig. 40. Ova of the itch animalcule. 

have concealed herself in the epidermis, and the burrow which she con- 
structs is arched and tortuous, and four or five lines in length, shorter 
or longer. The acarus has the shape of a tortoise. It can, when fully 
grown, be detected by the eye as a minute whitish point. The young 
acarus has six, the mature eight, articulated legs, with suckers upon the 
two anterior pairs, and hairs on the posterior. The head, which can be 
elongated or retracted, is provided with two jaws. The upper surface 



TREATMENT. 855 

is covered with spines directed backward so as to prevent retrogression 
in the burrow. She leaves behind her in the cuniculus, as she advances, 
her moulted skin, excreta, and eggs, which hatch on the eleventh day. 
The mother acarus is always found at the remote end of the burrow, 
where it can be seen by the unassisted eye as a minute whitish or some- 
times brownish speck, and from which it can be lifted by the point of a 
needle, to which it clings. The cuniculi can also be seen by the naked 
eye, looking, sa} T s Niemeyer, like the " scars of needle scratches," and 
containing the young acari in various stages of growth. 

The acarus by its burrowing produces an irritation and troublesome 
itching, which is the chief cause of the suffering of the patient. At the 
point where the acarus penetrates the cuticle the inflammation gives rise 
to a single, small, and acuminate vesicular or papular eruption, the 
cuniculus extending away from it. We often find ecthymatous pustules 
and abrasions intermingled with the vesicles, the result of frequent 
scratching. The itching is most intense, and the acarus most active, 
at night, when the patient is warm in bed. Scabies most frequently 
appears, especially in adults, first upon the hands, between the fingers, 
where the skin is thin, and it extends thence along the forearm, and 
over the thighs and abdomen. In children it not infrequently occurs 
upon the buttocks, thighs, feet, etc., while the hands and forearm 
escape. 

Diagnosis. — Correct diagnosis is important, because the treatment re- 
quired is different from that in any other exanthem, and because the 
suspicion of having this disease always renders one solicitous to know 
the exact nature of the eruption. Scabies can be diagnosticated from 
those diseases for which it may be mistaken by the following charac- 
ters : its occurrence where the cuticle is thin and delicate, as between 
the fingers, along the anterior aspect of the forearm, upon the abdomen, 
thighs, and inside of the feet ; small size, acuminate shape, and isolated 
position of vesicles ; the intermingling with the vesicles of other forms 
of eruption, as papules and pustules, and the presence of linear scars 
and abrasions produced by the scratching; itching most intense at 
night ; absence of fever ; absence of the disease from posterior aspect 
of body and arms, and from head and face. Scabies , may be distin- 
guished by the vesicular character of the eruption from all other exan- 
thematic affections except eczema, sudamina, and herpes. Eczema is 
most common on the scalp and face, where scabies does not occur, and 
unlike scabies its vesicles are round and thickly aggregated in clusters ; 
in eczema there is a smarting or prickling sensation very different from 
the intense itching of scabies. In herpes the vesicles are large, rounded, 
and in clusters, and attended by a burning or pricking sensation, with 
but little itching. This eruption in sudamina is vesicular and discrete, 
as in scabies, but it is globular, and accompanied by no itching or other 
local symptoms. 

Treatment. — As scabies is due to a species of acarus which burrows 
in the epidermis, it can only be treated successfully by measures which 
destroy this animalcule. If it be destroyed, the disease gets well of 
itself. Sulphur has been employed for a long period for this purpose, 
since sulphurous acid, which is evolved from the sulphur, is destructive 



856 SCABIES. 

to the animalcule. The unguentum sulphuris, if thoroughly applied, 
will rarely fail to eradicate scabies. The internal use of sulphur aids 
the externa] treatment, since a portion of the gas which is .generated 
escapes through the pores of the skin. The chief objection to the 
employment of sulphur is its exceedingly unpleasant odor, which is 
noticeable, however disguised by perfume. Sulphur or any other sub- 
stance employed externally has more effect if it be preceded by a bath, 
which softens the epidermis, and therefore favors the entrance of the 
remedy into the pores of the skin and the cuniculi. 

Helmerich's ointment is very effectual in the treatment of scabies. 
It consists of two parts of sulphur, one of carbonate of potassium, and 
eight of lard. "M. Hardy afterward perfected the method, so as radi- 
cally to cure the disease in two hours. He proceeded in the following 
manner : The patient first undergoes a friction of his whole body for 
half an hour with soft soap, in order to cleanse the skin and break up 
the burrows ; a warm bath of an hour's duration follows, during which 
the skin is thoroughly rubbed, in order to complete the destruction of 
the burrows ; after which frictions for half an hour and upon the whole 
surface are practised with Helmerich's ointment. This completes the 
cure. Out of four hundred patients subjected to this treatment, only 
four returned to the hospital. ' ' 1 

M. Albin Gras experimented with different substances, in order to 
ascertain their relative destructiveness to the acarus. The following 
table gives some of the results of his experiments : 

Immersed in pure water the acarus was alive after three hours. 

" saline water the acarus moved freely after three hours. 

1,1 Goulard's solution the acarus lived after one hour. 

u olive, almond, or castor oil the acarus lived more than two hours. 

" lime-water the acarus died in three-fourths of an hour. 

" vinegar " " twenty minutes. 

" alcohol " " " " 

" turpentine " " nine " 

" iodide of potassium the acarus died in four to six minutes. 

It is seen that vinegar, lime-water, alcohol, turpentine, and iodide of 
potassium destroy the acarus in a short time. They may be employed 
in the same manner as the sulphur ointment. Camphor is also destruc- 
tive to this animalcule, and the linimentum camphorae, thoroughly 
applied, is a good remedy for uncomplicated scabies. 

In order to avoid the odor of sulphur, which is so offensive, one of 
the following ointments may be employed, if the patient be fastidious : 

R. — Unguent, hydrarg. ammoniat ^j. 

Moschi gr. ij. 

01. lavendul. gtt. ij. 

01. amygdnl. gj. — Misce. 2 

If scabies be extensive this should not be used, as its application over 
considerable area might endanger salivation, but the following, which is 

1 Sti lie's Therapeutics, etc., vol. li. p. 516. 2 From Wilson. 



TREATMENT. 857 

recommended by Bazin, and is said to cure the disease with three appli- 
cations, may be used instead : 

R . — Anthemis pulv \ 

Adipis, I ...... aa ^j. — Misce. 

01. olivae, j 

In cases which have been protracted, and in which ecthymatous and 
other secondary eruptions have occurred, the scabies can ordinarily be 
readily cured, while the other eruptions remain and disappear more 
slowly. A knowledge of this is important, since the sulphur or other 
ointment employed for the cure of scabies, should be discontinued when 
the itching ceases and vesicles no longer appear, and tonic or other 
treatment appropriate to cure these secondary eruptions, should be 
employed instead. The sulphur ointment continued after the scabies 
is cured does harm, as it irritates the cuticle. It is essential in the 
treatment of scabies that the linen be frequently changed. 



INDEX. 



«£ { B. C." cereal milk, analysis of, 

A. i>s 

Abdomen in disea-e, 100 

in rachitis, 127 
Abdominal viscera in tuberculosis, 143 
Abscess, cervical, 145, 221 

pelvic, in constipation, 752 
strumous, 138, 145 
Acarus scabiei, 854 
Acephalus, 415 

anatomical characters, 415 
symptoms, 416 
prognosis, 416 
Adenitis, diphtheritic, 307 
scarlatinous, 221 
strumous, 138, 145 
Adhesions, peritoneal, a cause of consti- 
pation, 752 
Alvine discharges a cause of constipa- 
tion, 754 
in disease, 101 
" American Swiss " infant food, analysis 

of, 58 
AnEemia a cause of chorea, 514 

modification of mother's milk by, 39 
Analysis of milk, 57, 58 

of infant foods, 58 
Anencephalus (see Acephalus). 
" Anglo-Swiss " infant food, analysis of, 

58 
Animal heat in infancy, 99 
Anthelmintics, 776 
Anus, occlusion of, 750 
Apnoea neonati, 71 
causes, 72 
treatment, 72 

artificial respiration in, 72 
Apoplexy (see Intercranial hemorrhage). 
Appearance in disease, 91 
Arthritis (see Rheumatism). 
Artificial feeding, directions for, 49, 57, 
61 
respiration, 72 
Ascaris lumbricoides, 773 
Asphyxia neonati (see Apnoea neonati). 
caused by intestinal worms, 766 
Asthma, Kopp's (see Internal convul- 
sions). 
Atelectasis, 605 
acquired, 606 
causes, 606 
symptoms, 607 
anatomical characters, 607 
treatment, 608 



Atomizer in diphtheria, 322 

in pertussis, 335 
Atrophy, muscular, 531 
Attitude in disease, 93 



BABY foods (see Infant foods). 
;( Baby Sup," analysis of, 58 
Bacillus, tubercle, 172 
Bathing in infancy, 66 
Bile, purpose of, 60 
Bladder, anatomy of, 811 

irritability of, 813 
" Blair's " wheat food, analvsis of, 58 
Blood in diphtheria, 308 

poisoning in scarlet fever, 243 
Blue disease, 823 
Bone, rachitic, analysis of, 114 
i Bones, modification of, by rachitis, 113 
cranial, in rachitis, 116 
Brain, absence of, 415 
atrophy of, 418 
composition of, 414 
congestion of, 429 
causes, 429 
symptoms, 431 
anatomical characters, 431 
prognosis, 432 
treatment, 432 
disease of, 413 
. dropsy of, 442, 449 
development of, 414 
hypertrophy of, 420 

pathological anatomy, 420 
causes, 421 
symptoms, 421 
diagnosis, 423 
prognosis, 424 
treatment, 424 
imperfect, 417 
case of, 417 
symptoms, 418 
prognosis, 418 
in infancy, 18, 414 

membranes of, 415 
hemorrhage in and upon, 433 
fever (see Meningitis). 
Breast milk (see Milk, human). 

inflammation of, 32 
Bright's disease (see Nephritis). 
Bronchial glands, tubercles of, 161, 168 

phthisis, 161 
Bronchitis, 593 
causes, 594 

(859) 



860 



INDEX 



Bronchitis, anatomical characters, 594 
symptoms, 597 
duration, 599 
chronic, 599 
diagnosis, 599 
prognosis, 600 
treatment, 600 
in measles, 188, 191 
tubercular, 158 



CALCULUS, vesical, a cause of enu- 
resis, 812 
Cancer, aqueous, of infante, 673 
Cancrum oris (see Gangrene of mouth). 
Capillary bronchitis in measles, 191 
Caput succedaneum, 73 
Cardiac degeneration in diphtheria, 308 

malformations, 823, 834 
Care of mother in pregnancy, 19 
Caries, vertebral, 551 
Cartilages in rachitis, 113 
Catarrhal laryngitis, 559 
pharyngitis, 687 
pneumonitis, 609, 612 
Cellulitis, strumous, 140 

scarlatinous, 221 
Cephalsematoma, 73 

Cephalalgia in meningeal tubercles, 166 
Cerebral hemorrhage (see Intracranial 
hemorrhage), 
tubercles, 167 
Cerebro-spinal disease a cause of consti- 
pation, 754 
Cerebro-spinal fever, 358 

etiology, 358 

non-contagiousness of, 360 

sex, 363 

age, 363 

mode of commencement, 365 

symptoms, 364, 367 

pulse, 373 

temperature, 373 

respiratory system, 375 

cutaneous system, 376 

urinary organs, 376 

special senses, 377 

nature, 380 

anatomical characters, 382 

prognosis, 387 

diagnosis, 389 

treatment, 390 
Cerebro-spinal system, diseases of, 413 

meningitis, 358 
Cheesy pneumonitis, 614 
Chickenpox, 293 
Childhood, duration of, 19 

changes of organs in, 19 
Cholera infantum, 734 
Choleriform diarrhoea. 734 

anatomical characters 735 

nature, 738 

diagnosis, 739 

prognosis, 739 

treatment, 739 
Circulation, changes in, at birth, 18 



Circulatory system in infancy, 96 

diseases of, 823 
Clavicle in rachitis, 124 
Clothing in infancy, 67 
Colitis in childhood, 718 
Colostrum, 28, 33 

examination of, 28 

constituents of, 29, 33 

microscopic appearance, 33 

purpose of, 34 

injurious effects of, on infant, 35 

a cause of diarrhoea, 724 
Colustrum corpuscles, 33 
Condensed milk, 64 
Congenital hydrocephalus, 442 
Congestion of brain, 429 

of spinal cord and membrane?, 545 
anatomical characters, 

546 
symptoms, 546 
treatment, 546 

of stomach, 704 
Conjunctivitis, gonorrhoeal, 822 
Constipation, 750 

congenital, 750 

symptomatic, 750 

causes, 741 

idiopathic, 754 

symptoms, 755 

symptomatic cases, 755 

idiopathic cases, 756 

treatment, 759 

hygienic, 759 

therapeutic, 762 

in intussusception, 788, 796 

cases of extreme, 756 

alternating with diarrhoea, 758 
Constitutional diseases, 105 
Consumption (see Tuberculosis). 
Convulsions, clonic (see Eclampsia). 

in cerebral tuberculosis, 167 

internal (see Laryngismus stridulus). 

in pertussis, 330 

in diphtheria, 310 

in measles, 192 

in scarlet fever, 264 
Coryza, 556 

anatomical characters, 557 

symptoms, 557 

prognosis, 557 

treatment, 557 

in scarlet fever, 228 

syphilitic, 180 

treatment, 186 
Cranial bones in rachitis, 116 
Craniotabes in rachitis, 117 
Croup, diphtheritic, 310 

false (see Laryngitis, spasmodic). 

membranous, 567 

etiology of, 567 

anatomical characters, 571 

symptoms, 573 

diagnosis, 574 

prognosis, 575 

treatment, 576 

true (see Croup, membranous). 



INDEX 



861 



Croup, in measles, 192 

Croupous pneumonitis 609, 611 

Cryptorchia, 820 

Cutaneous appearances in disease, 92 

diseases, 840 
Cyanosis, 823 

literature, 824 

sex, 826 

causes of cardiac deformity, 826 

age, 827 

symptoms, 829 

prognosis, 833 

modes of death, 833 

heart lesions in, 835 

morbid anatomy, 835 

etiology, 836 

treatment, 838 



DACTYLITIS, strumous, 139 
syphilitic, 183 
Death in infancy, 23 

rate in infancy, 24 
Deformity, hereditary transmission of, 22 

in foetus, due to maternal impres- 
sions, 20 
Dentition, 680 

pathological results of, 681 

diagnosis, 683 

treatment, 684 

second, 685 

in rachitis, 126 

in syphilis, 184 

its relation to diarrhoea, 724 
Diagnosis of infantile diseases, 90 
Diarrhoea, inflammatory (see Intestinal 
catarrh of infants). 

summer (see Entero-colitis). 

following constipation, 758 

a cause of intussusception, 788 

non-inflammatory, 713 

causes, 714 

symptoms, 714 

anatomical characters, 715 

prognosis, 716 

treatment, 716 
Diathetic diseases, 105 
Diet a cause of rachitis, 109 

a cause of entero-colitis, 724 

a cause of infant mortality, 27 

a cause of constipation, 754 

of mother in pregnancy, 19 

of mother during lactation, 43 

effects of, on milk secretion, 36 

of infant, 49 
Digestion, disorders of, 697 
Digestive system in infancy, 100 

secretions, action of, 60 
Diphtheria, 295 

age, 295 

incubative period, 296 

nature, 297 

causes, 297 

anatomical characters, 304 

symptoms, 309 

diagnosis, 314 



Diphtheria, prognosis 314 
causes of death, 315 
treatment, 316 
general, 318 
stimulants, 318 
tonics, 319 
local, 322 
preventive, 324 
of complications, 315 
measles, 93 
scarlet fever, 225, 254 
constitutional, 301 
primary, 297 
secondary, 297 
Diphtheritic croup, 310 
gastritis, 708 
nephritis, 302, 311 
paralysis, 313, 324 
Dysentery in children, 747 
Dyspepsia, 697 
Dysuria, 819 



EAR, scarlatinous affections of, 228 
strumous affections of, 141 
Eclampsia, 476 
causes, 476 

premonitory stage, 477 
symptoms, 478 
anatomical characters, 480 
diagnosis, 481 
prognosis, 482 
treatment, 483 
in cerebral tubercles, 167 
in diphtheria, 310 
in measles, 192 
in scarlet fever, 228 
in pertussis, 330 
Eczema, 847 

anatomical characters, 848 
acute, 848 
chronic, 848 
etiology, 848 
varieties, 848 
rubrum, 849 
impetiginosum, 849 
diagnosis, 850 
treatment, 850 
in acute, 850 

constitutional, 850 
external, 851 
pruritus, 852 
in chronic, 852 
Elixir adjuvans, 103 
Emetics in croup, 588 
Emphysema in rachitis, 130 

in tuberculosis, 160 
Empyema, 651 
Encephalocele, 74 
Encephalon, tubercles in, 166 
Endocarditis in rheumatism, 400 

treatment, 403 
Enteritis, 747 
Entero-colitis, 718 
in measles, 192 
Enuresis, 811 



s<)2 



INDEX 



Enuresis, occurrence, 81 1 
etiology, 822 
nervous, 813 
prognosis, 814 
treatment, 815 
Eruptive fevers, 188 
Erys pelas, 404 
" age, 406 
point of invasion, 406 
cause, 406 

premonitory symptoms, 409 
symptoms, 409 
prognosis, 410 
duration, 410 
modes of death, 410 
pathological anatomy, 410 
treatment, 411 
in nursing mother, 32 
after vaccination, 405 
Erythema, idiopathic, 840 
simplex, 840 
intertrigo, 840 
la3ve, 841 
symptomatic, 841 
fugax, 841 
papulum. 841 
tuberculum, 841 
nodosum, 841 
prognosis, 841 
diagnosis, 841 
treatment, 842 
fugax in diphtheria, 312 
Erythematous diseases, 839 
Exercise in infancy, 70 
Extractum pancreatis, 61 
Eye, strumous affections of, 148 
in measles, 188 



FACIAL paralysis, 538 
causes, 538 
symptoms, 539 
prognosis, 539 
treatment, 539 
Farinaceous infant foods, 58 
Febrile affections in nursing mother, 

31 
Feeding, improper, a cause of infant 
mortality, 27 
infant (see Infant food). 
Femur in rachitis, 125 
Fever and ague (see Intermittent fever). 
Fever, malarial (see Intermittent fever). 
Fibula in rachitis, 125 
Fingers, bulbous enlargement of, 92 
Foetus, effects of maternal impressions 
on, 20 
injury of, in utero, 22 
syphilis in, 178 
Follicular gastritis, 70S 
Food, improper, a cause of rachitis, 
109 
quantity required (see Diet), 51 
French measles (see Kotheln) 
Fright a cause of chorea, 519 



GALACTOGOGUES, 44 
Galactorrhcea, 40 
Gangrene of mouth, 673 

anatomical characters, 673 
age, 674 
causes, 674 
symptoms, 675 
diagnosis, 676 
prognosis, 676 
treatment, 677 
following measles, 193 
Gastric juice, purpose of, 60 
Gastritis, 704 
cause 705 
age, 705 
symptoms, 706 
anatomical characters, 707 
diagnosis, 707 
prognosis, 707 
treatment, 708 
follicular, 708 
diphtheritic, 708 
Gastro-intestinal hemorrhage, 781 
in newborn, 781 
causes, 782 
purpuric, 783 

causes, 783 
local, 784 

causes, 784 
frequency, 784 
case of, 784 
prognosis, 785 
treatment, 785 

regimenal, 785 
therapeutic, 786 
Gelatine as an infant food, 65 
Genito-urinary diseases, 810 

organs, 232 
"Gerber's milk food," analysis of, 58 
Germ cultivation, 198 
German measles (see Kotheln). 
Glandular system in struma, 137 

in scarlet fever, 221 
Glottis, spasm of (Larvngismus stridu- 
lus). 
Gonorrhoea in the child, 821 
Growth of infants, 28 



HEMOPTYSIS in infant tubercu- 
losis, 170 
" Hawley's Infant Food," 58 
Heart, dilatation of, after scarlet fever, 
231 

malformations of, 823 

lesions in rheumatism, 400 
Hemorrhage, umbilical, 27 

intercranial, 433 

intestinal, in intussusception, 796 

gastro-intestinal, 781 
Hernia, a cause of constipation, 751 
Hip-joint disease, 551 
Hives (see Urticaria). 
" Horlick's Infant Food," 58 
"Hubbell's Wheat Food," 58 



J N D E X 



863 



Human milk (see Milk, human). 
Huiimnized cows' milk, 62 
Humerus in rachitis, 124 
Hydrencephalocele, 74 
Hydrocephalus, acquired, 449 

causes, 449 

anatomical characters, 450 

symptoms, 450 

prognosis, 452 

treatment, 452 
congenital, 442 

anatomical characters, 442 

etiology, 445 

symptoms, 446 

diagnosis, 447 

prognosis, 448 

treatment, 448 
spurious, 470 

anatomical characters, 378 

symptoms, 471 

diagnosis, 474 

prognosis, 474 

treatment, 475 
Hyperemia in nursing women, 48 



TCTEEUS neonati, 91 

1 Idiocy, congenital, due to maternal 

impressions, 2 
Imitation a cause of chorea, 519 
Imperforate rectum, 705 
" Imperial G-ranum," analysis of, 58 
Indigestion, 697 
causes, 697 
symptoms, 699 
prognosis, 700 
diagnosis, 701 
treatment, 701 
Infancy, 17 

period of, 17 
organs in, 17, 18 
secretions in, 17 
integument in, 17 
appetite in, 18 
thymus gland in, 18 
kidney in, 18 
senses in, 18 
mental faculties in, 18 
Drain in, 18 
stomach in, 18 
mortality of, 23 
signs of disease in, 90 
sleep during, 69 
exercise in, 70 
artificial food in, 57 
Infant mortality, 23, 24 

period of greatest, 23 
causes, 24 

internal malformations, 24 
feebleness of system, 24 
hereditary disease, 24 
infectious diseases, 25 
antihygienic conditions, 25 
exposure to cold, 26 
improper feeding, 27 
prevention of, 25 



Infant growth, 28 
care of, 63 
bathing, 66 
clothing, 66 
food, 49 

analysis of, 58 
quantity required, 51 
artificial, 57 
hygiene, 66 
therapeutics, 103 
weight of, 28 
Infantile paralysis, 528 
symptoms, 530 
prognosis, 532 
progress, 532 
etiology, 533 

anatomical characters, 536 

diagnosis, 536 

prognosis, 536 

treatment, 537 

Injury to foetus in utero, 22 

to mother a cause of miscarriage, 22 
Integument, character of, in infancy, 17 
Intercranial hemorrhage, 433 
causes, 433 

anatomical characters, 434 
meningeal, 435 
cerebral, 426 
symptoms, 437 
diagnosis, 440 
prognosis, 441 
treatment, 441 
Intermittent fever, 342 
causes, 342 

incubative period, 343 
symptoms, 343 
treatment, 346 
Internal convulsions, 504 
causes, 505 

anatomical characters, 507 
symptoms, 507 
diagnosis, 509 
prognosis, 509 
modes of death, 509 
treatment, 510 
Intestinal catarrh of infancy, 718 
etiologv, 720 
age, 726 
dentition, 726 
symptoms, 726 
anatomical characters, 730 
diagnosis, 734 
prognosis, 734 
treatment, 730 
curative, 740 
medicinal, 741 
external, 746 
dejections, morbid indications in. 

101 
displacements, 751, 787 

a cause of constipation, 751 
secretions, 60 
worms, 765 

ascaris lumbricoides, 765 
oxyuris vermicularis, 767 
taenia, 768 



864 



INDEX. 



Intestinal worms, tricocephalus dispar, 
771 
causes, 773 
symptoms. 773 
diagnosis, 776 
prognosis, 776 
treatment, 776 
Intestine, displacement of, 751 
hemorrhage from, 781 
invagination of, 787 
intussusception of, 787 
obstruction of, 750 
in tuberculosis. 173 
irritation of, a cause of chorea, 
520 
Intussusception, 787 

without symptoms, 787 

post-mortem form, 787 
with symptoms, 788 
previous health, 788 
causes, 788 
sex, 788 
age, 789 
seat, 790 

pathological anatomy, 790 
small intestine, 790 

cases, 790 
large intestine, 793 
incomplete, 794 
symptoms, 796 
diagnosis, 797 
duration, 798 
prognosis, 798 
modes of death, 800 
treatment, 801 

by injection, ftOl 

by inflation, 804 

laparotomy, 807 

Invagination of the intestine, 787 

Itch (see Scabies). 



JAUNDICE of newborn {see Icterus 
neonati) a cause of umbilical hemor- 
rhage, 89 
Joints, inflammation of (see Rheumatism) 



KEASBEY and Mattison's infant food, 
58 
Keratitis, strumous (see Strumous oph- 
thalmia), 
herpetic, 149 

phlyctenular, 149 
vascular, 149 
parenchymatous, 151 
symptoms, 151 
non- vascular, 151 
duration, 152 
causes, 152 
treatment, 152 
Kidnev, congenital cvstic, degeneration 
of, 18 
inflammation of (see Nephritis). 
in rachitis, 128 
uric acid infarctions of, 810 



Kopp's asthma (see Laryngismus stridu- 
lus). . 
Kvohosis in rachitis, 121 



T ACTATION, 28 
Li abnormal, 41 

care of mother during, 29 
communication of disease by, 45 
diet during, 43 
directions for, 28 
hinderances to, 29 
tuberculosis, 30 
erysipelas, 32 
mastitis, 32 
menstruation during, 47 
termination of, 65 
Lactic acid as a cause of rachitis, 110 
Lactometer, 46 
Lactoscope, 46 

Laryngismus stridulus (see Convulsions, 
internal). 
in rachitis, 127 
Laryngitis, catarrhal, 559 
symptoms, 559 
chronic, 560 

anatomical characters, 561 
treatment, 561 
pseudo-membranous (see Croup, 

membranous), 
spasmodic, 562 
causes, 562 
symptoms, 562 
anatomical characters, 563 
diagnosis, 563 
prognosis, 564 
treatment, 564 
tubercular, 157 
Laxatives in diarrhoea, 717 
Liebig's infant food, preparation of, 63 
analysis of, 58 
in constipation, 760 
Ligaments in rachitis, 127 
Liver in rachitis, 127 
Lividity of newborn, 91 
Lockjaw, 485 
Lordosis in rachitis, 126 
Lung, inflammation of (seePneumonitis). 
in tuberculosis, 158, 169 
oedema of, in diphtheria, 315 



MALE fern in tsenia, 780 
Malignant scarlet fever, 217 
Mastitis, 32 

Maternal impressions, effects on foetus, 20 
Maxilla in rachitis, 121 
Measles, 188 

etiology, 188 

symptoms, 188 

complications, 191 

anatomical characters, 193 

nature, 194 

diagnosis, 194 

prognosis, 195 

treatment, 195 



INDEX. 



865 



Measles complicating rachitis, 132 
Meconium, 17 

composition of, 17 
Mellin's food, 58 

Membranous croup (see Croup, mem- 
branous). 
Meningeal hemorrhage (see Intercranial 
hemorrhage), 
tuberculosis, 166 
congestion, 545 
Meninges, congestion of, 545 
hemorrhage into, 433 
tubercles in, 166 
Meningitis, 452 

tubercular, 453 

non-tubercular, 453 

age, 454 

pathological anatomy, 455 

causes, 459 

symptoms, 461 

diagnosis, 466 

prognosis, 466 

treatment, 468 

cerebro-spinal (see Cerebro-spinal 

fever). 
a cause of constipation, 754 
Meningocele, 74 

Menstruation in lactation, 38, 47 
Mental excitement in pregnancy, 20 

impressions, effects of, on foetus, 20 
Mercury in syphilis, 185 
Microcephalus, 418 
Milk, asses', 59 
goat's, 59 
condensed, 64 
cow's, 35 

specific gravity of, 35 

modified by feeding, 36 

constituents of 35 

analysis of, 57 

compared with human, 59 

improper, a cause of diarrhoea, 

725 
humanized, 62 
condensed, 64 
human 

analysis of, 35, 57 
abnormal secretion, 41 
bacilli in, 46 
constituents of, 57 
examination of, 28, 45 
excessive secretion of, 40 

causes, 40 
modification by retention in 
breast, 36 
age, 37 

maternal impressions, 37 
pregnancv, 38 
diet, 36 

venereal excess, 39 
phthisis, 39 
anaemia, 39 
syphilis, 39 
nervous disorders, 39 
medicinal substances, 39 
pus in, 32 



Milk, human, differences in quality, 39 
quantity required by infants, 52 
scanty secretion of, 40 
causes, 40 

hypersemia, 41 
atrophy of breast, 
41 
treatment, 41, 43 
Miscarriage, prevention of, 19 

causes of, 19, 22 
Morbilli (see Measles). 
Morbus cseruleus, 823 
Mortality of early life, 23 
Mother, care of, in pregnancy, 19 
diet of, in pregnancy, 19 
care of, in lactation, 29 
Mouth, gangrene of, 673 
after measles, 193 
inflammation of (see Stomatitis). 
Mucous patches in syphilis, 180 
Muguet (see Thrush). 
Mumps (see Parotiditis). 
Muscular atrophy, 531 
Myelitis a cause of constipation, 754 



NECROSIS, treatment, 324 
infantile (see Gangrene of mouth). 
Nephritis, 232 

parenchymatous, 234 
pathology of, 234 
interstitial, 236 

pathology of, 236 
symptoms, 237 
treatment, 259 
Nephritis, diphtheritic 302 

scarlatinous, 212 
Nervous cough, 660 

treatment, 661 
system in disease, 102 
Nestle's food, analysis, 58 
Nettle-rash, 845 

Newborn, asphyxia of (see Apnoea neo- 
natij. 
septicaemia of, 83 
weight of, 28 
Nipple, depressed, 29 

treatment of, 29 
fissure of, 30 
Noma (see G-angrene of mouth). 
Nurse, selection of, 39-44 
Nursing (see Lactation), 
frequency of, 39-48 



OBSTETRICAL scarlet fever, 208 
(Edema glottidis in scarlet fever, 223 
general, in scarlet fever, 237 
i Oesophagitis, 696 

anatomical characters, 696 
symptoms, 697 
Oidium albicans, 669 
Ophthalmia, herpetic, 149 
symptoms, 149 
duration, 149 
diagnosis, 149 



55 



866 



INDEX. 



Ophthalmia, herpetic, cause?, 149 
prognosis, 150 
treatment, 150 
parenchymatous, 151 
symptoms, 151 
duration, 152 
treatment, 152 
phlyctenular (see Herpetic). 
in measles, 143 
neonati, 77 
causes, 77 
symptoms, 78 

blenorrhceal form, 78 
catarrhal form, 78 
treatment, 79 
strumous, 148 
Ophthalmoscope in cerebral diseases, 413 
Osseous system in rachitis, 113 
Osteosclerosis, 128 
Otitis in scarlet fever, 228 
treatment, 256 
in struma, 141 
Otorrhcea in scarlet fever, 228 
treatment, 256 
in strurna, 141 
Oxyuris vermicularis, 767 



PAIN as an indication of disease, 102 
Pancreatic juice, purpose of, 60 
Papular cutaneous disease, 846 

eczema, 849 
Paralysis, facial, 538 
diphtheritic, 313 

treatment, 324 
in cerebral tuberculosis, 167 
infantile, 528 

with pseudo-hypertrophy, 540 
symptoms, 540 
anatomical characters, 542 
causes, 543 
prognosis, 543 
treatment, 543 
Parotid gland in infancy, 63 
Parotiditis, 339 
nature, 340 
diagnosis, 340 
treatment, 340 
Parotitis (see Parotiditis). 
Pemphigus in syphilis, 181 
Peptonized milk, 61 

method of preparing, 61 
Pericarditis in scarlet fever, 230-265 
Pericardium, tubercles of, 163 
Period of greatest infant mortality, 23 
Periostitis, strumous, 139 

treatment, 147 
Peripharyngeal abscess, 690 
age, 690 
cause, 690 

anatomical characters, 691 
symptoms, 692 
diagnosis, 694 
treatment, 695 
Peritonitis a cause of constipation, 352 
tubercular, 752 



I Pertussis, 325 
age, 326 
causes, 326 

pathological anatomy, 327 
symptoms, 328 
complications, 330 
diagnosis, 333 
prognosis, 334 
treatment, 335 
Pharyngitis, catarrhal, 687 

anatomical characters, 687 
causes, 688 
symptoms, 688 
prognosis, 688 
diagnosis, 689 
treatment, 689 
diphtheritic, 304-310 

treatment, 322 
scarlatinous, 212-254 
Pharynx, ulceration of, in scarlet fever, 

223 
Phimosis a cause of dysuria, 820 
Phthisis (s'ee Tuberculosis), 
bronchial, 161 
in nursing mother, 39 
Pleura, tuberculosis of, 160 
Pleurisy (see Pleuritis). 
Pleuritis, 622 

frequency, 623 
causes, 623-628 
anatomical characters, 629 
plastic, 630 
sero-fibrinous, 630 
purulent, 631 
hemorrhagic, 632 
symptoms, 636 
physical signs, 639 

palpation, 639 
percussion, 640 
auscultation, 640 
diagnosis, 642 
prognosis, 644 
treatment, 646 
external, 647 
internal, 647 
thoracentesis, 657 
empyema, 651 

operating, mode of, for serofibrinous 

exudation, 652 

for empyema, 653 

admission of air, 655 
injurv to lung by nee- 

dle) 656 
washing out pleural 

cavity, 657 
tent and drainage-tube, 
659 
exsection of ribs, 660 
Pneumonia (see Pneumonitis). 
Pneumonitis, 609 
lobar, 609 
croupous, 609 
interstitial, 609 
catarrhal, 609 
causes, 609 
anatomical characters, 611 



INDEX 



867 



Pneumonitis, cheesy, 614 

symptoms, 615 

physical signs, 617 

diagnosis, 618 

prognosis, 619 

treatment, 620 
catarrhal, 620 
croupous, 620 
local, 622 

in measles, 192 

in pertussis, 331 

in rheumatism, 403 
Post-mortem gastric softening, 709 
Pott's disease, 551 
Pregnancy, care of mother in, 19 

diet of mother in, 19 

exercise of mother in, 19 

disease of mother in, 20 
intermittent fever, 20 
syphilis in, 20 

changes in milk of mother in, 38 
Prolapsus recti, 758 

Pseudo-membranous croup (see Mem- 
branous croup). 
Panophthalmia, strumous, 141 
Pulse in health, 97 

in disease, 98 

in infancy, 97 

influenced by excitement, 98 
Pus in milk, 32 



RACHITIS, 105 
frequency, 105 
age, 107 
causes, 109 

artificial production, 110 
anatomical characters, first stage, 1 12 

pathology of, 115 
anatomical characters, second stage, 
115 
cranium in, 116 
craniotabes, 117 
vertebrae in, 120 
kyphosis in, 121 
lordosis in, 121 
scoliosis in, 121 

bones of upper extremity in, 124 ! 
pelvis in, 124 

bones of lower extremity in, 125 i 
soft tissues, 127 
anatomical characters, third stas;e, j 
128 
symptoms, 129 

complications and sequelae, 130 
diagnosis, 131 
prognosis, 132 
treatment, 133 
Radius in rachitis, 124 
Rectum, hemorrhage from, 781-796 
imperforate, 750 
occlusion of, 750 
prolapsus of, 758 
stenosis of, 750 
Remittent fever, 347 

symptoms, 347 



Remittent fever, diagnosis, 348 

treatment, 348 
Respiration in infancy, 94 
in health, 94 
in disease, 95 
Rheumatism, acute, 398 
causes, 399 
symptoms, 399 
duration, 401 
prognosis, 401 
diagnosis, 402 
treatment, 402 
pneumonitis in, 403 
endocarditis in, 400 
treatment, 403 
a cause of chorea, 514 
in scarlet fever, 229-265 
Ribs, changes in, in rachitis, 122 
exsection of, in pleuritis, 660 
Rickets (see Rachitis). 
Ridge's infant food, analysis of, 58 
Robinson's patent barley, analysis of, 58 
Roseola, 843 

idiopathic, 843 

varieties, 843 
symptomatic, 843 
varieties, 843 
symptoms, 843 
causes, 844 
prognosis, 844 
diagnosis, 844 
treatment, 844 
syphilitic, 180 
Rotheln, 265 
history, 266 
premonitory stage, 267 
symptoms, 268 
tegumentary system, 268 
respiratory system, 269 
digestive system, 269 
pulse, 270 
temperature, 270 
complications, 270 
prognosis, 270 
nature, 271 

incubative period, 271 
Round worm (intestinal], 765 
Rubeola (see Measles). 



SALIVA, purpose of, 60 
Santonin, European, in worms, 777 
Savory & Moore's infant food, analysis, 58 
Scabies, 854 
cause, 854 
diagnosis, 855 
treatment, 855 
Scapula in rachitis, 124 
Scarlatina (see Scarlet fever). 
Scarlatinous nephritis, 232-259 
Scarlet fever, 197 

history, 197 
etiology, 197 
incubative period, 202 
. contagiousness of, 204 
variations in type, 204 



868 



INDEX. 



Scarlet fever, surgical, 205 
obstetrical, 205 
age, 210 

clinical facts, 211 
symptoms, 213 
malignant type, 217 
irregular forms, 219 
complications, 220 
sequelae, 220 
adenitis in, 221 
nephritis in, 232 
anatomical characters, 238 
diagnosis, 240 
prognosis, 241 
treatment, 244 

prophylactic, 244 
hygienic, 247 
therapeutic, 258 
in mild cases 248 
in ordinary and severe, 249 
antiseptic, 253 
complications and sequelae, 
254 
Scoliosis in rachitis, 121 
Scrofula, 135 
causes, 136 

anatomical characters, 137 
symptoms, 140 
prognosis, 142 
treatment, 143 

prophylactic, 143 
curative, 143 
ophthalmia in, 148 
Secretions in infancy, 17 
Septicaemia in diphtheria, 301-307 
in newborn, 83 
in scarlet fever, 243 
Skin, appearance in syphilis, 180 
diseases of, 840 
in disease, 92 
in infancy, 17 
Smallpox, 274 

Solvents of pseudo-membrane, 322-579 
Spasmodic laryngitis, 562 
Spasm of glottis (see Laryngismus stri- 
dulus). 
Spigelia in intestinal worms, 777 
Spinal cord, congestion of, 545 

diseases of, 413-544 
Spina bifida, 547 

anatomical characters. 547 
diagnosis, 549 
prognosis, 549 
treatment, 549 
Spine (see Thrush). 
Spleen in rachitis, 127 
Spurious hydrocephalus, 470 
Starch, digestion of, by infants, 62 
St. Guy's dance (see Chorea). 
Stomach, congestion of, 704 
diseases of, 697 
inflammation of, 704 
post-mortem softening of, 709 
in tuberculosis, 163 
Stomatitis, 663 
simple, 663 



Stomatitis, catarrhal, 663 
symptoms, 664 
appearance, 664 
treatment, 664 
ulcerous, 665 
causes, 665 
symptoms, 666 
prognosis, 666 
treatment, 666 
aphthous, 667 

causes, 647 

symptoms, 667 

diagnosis, 668 

prognosis, 668 

treatment, 668 
Strabismus a sign of infant disease, 92 
Strophulus, 846 
varieties, 846 
appearance, 846 
treatment, 847 
Struma (see Scrofula). 
Strumous ophthalmia, 148 

duration, 149 

diagnosis, 147 

causes, 149 

prognosis, 150 

treatment, 150 
St. Vitus's dance (see Chorea). 
Syphilis, 177 

etiology, 177 

contagiousness of, 177 

clinical history, 178 

congenital, 178 

age of appearance, 179 

in foetus, 178 

visceral lesions in, 181 

osseous lesions in, 182 

prognosis, 184 

treatment, 185 

in nursing mother, 31 

in lactation, 39 

communicated by lactation, 45 



TAENIA, 768 
solium, 769 

saginata, 770 

medico-canejlata, 770 

elliptica, 770 

cucumerina, 770 

bothriocephalus, 771 

tricocephalus dispar, 771 

treatment, 779 
Tape-worm (see Taenia). 
Teeth in rachitis, 126 

in syphilis, 184 
Teething (see Dentition). 
Temperature, atmospheric relation to 
diarrhoea, 720 

in disease, 99 

in infants, 99 
Tetanus infantum, 485 

commencement, 487 

frequency, 488 

causes, 489 

symptoms, 498 



INDEX 



869 



Tetanus, mode of death, 500 
prognosis, 500 
duration in fatal cases, 500 
diagnosis, 501 
treatment, 502 
Therapeutics, infantile, 103 
Thoracentesis, 
Thorax in tuberculosis, 170 

in rachitis, 123 
Thread-worms, 767 
Thrombosis in cranial sinuses, 424 

anatomical characters, 425 
causes, 427 
symptoms, 427 
diagnosis, 428 
prognosis, 428 
treatment, 428 
of umbilical vein, 83 
Thrush, 669 

anatomical characters, 669 
symptoms, 670 
causes, 671 
diagnosis, 671 
prognosis, 671 
treatment, 672 
Tibia in rachitis, 125 
Toxaemia, diphtheritic, 301-307 
Tracheotomy, 575 
statistics of, 575 
in croup, 591 
directions for, 591 
instruments for, 592 
Tricocephalus dispar, 771 
Trismus (see Tetanus infantum). 
Tubage in membranous croup, 589 
Tubercle, anatomical characters of, 156 

bacillus, 153-172 
Tubercular laryngitis, 157 

pneumonitis, 617 
Tuberculosis, 153 
etiology, 853 
contagiousness, 155 
anatomical characters, 156 
symptoms, 165 
physical signs, 169 
lungs, 169 
pleura, 171 
stomach, 172 
intestines, 173 
diagnosis, 172 
prognosis, 175 
treatment, 175 

prophylactic, 175 
curative, 176 
in nursing mother, 30 
Typhoid fever, 348 
causes, 349 

anatomical characters, 350 
incubative period, 351 
symptoms, 353 
complications, 353 
diagnosis, 354 
duration, 355 
prognosis, 356 
treatment, 356 



ULNA in rachitis, 124 
Umbilical cord, management of, 82 
vein, thrombosis of, 83 
treatment, 86 
phlebitis of, 83 
granulations, 87 
fungus (see Umbilical granulations). 

treatment, 87 
hemorrhage, 87 
causes, 88 
symptoms, 89 
prognosis, 90 
treatment, 90 
Umbilicus, diseases of, 82 
inflammation of, 86 
causes, 86 
prognosis, 86 
treatment, 86 
ulceration of, 86 
Uraemia in scarlet fever, 237 
treatment, 259 
diphtheritic, 311 
Uric acid infarctions, 810 
Urine, extreme acidity of, 810 

a cause of enuresis, 812 
treatment, 810 
incontinence of, 811 
excessive amount, a cause of enu- 
resis, 812 
Urticaria, 845 

appearance, 845 
causes, 845 
prognosis, 845 
diagnosis, 845 
treatment, 845 
Uterine irritation a cause of chorea, 514 



yACCINATION (see Vaccinia). 
V Vaccine virus, 292 
Vaccinia, 283 

history, 284 

appearances, 286 

symptoms, 286 

anomalies, 287 

complications, 287 

sequela?, 289 

revaccination, 289 

erysipelas in, 405 

virus, selection of, 292 
Varicella, 293 

symptoms, 293 

diagnosis, 294 

prognosis, 294 

treatment, 294 
Variola, 274 

incubative period, 274 

stage of invasion, 275 
eruptive, 275 
desiccative, 277 

mode of death, 278 

anatomical characters, 279 

prognosis, 280 

diagnosis, 280 



870 



INDEX, 



Variola, treatment, 281 

mistaken for measles, 195 
Varioloid, 278 
Vein, umbilical, phlebitis of, 83 

thrombosis of, 83 
Venereal excess, effects of, on milk, 39 
Vermifuges, 776 
Vertebral caries, 551 

causes, 551 

symptoms, 553 

diagnosis, 554 

prognosis, 554 

treatment, 555 
Vertebrae in rachitis, 120 
Vibriones bacilli in human milk. 46 
Virus, vaccine, 292 
Visceral lesions in syphilis, 181 
Voice in disease, 93 
Volvulus, 751 

case of, 755 
Vomiting in constipation, 755 



Vomiting in meningeal tuberculosis, 166 

in intussusception, 796 
Vulvitis, 821 

aphthous, 821 

etiology, 821 

treatment, 822 



WEANING, 65 
menstruation in mothers as an in- 
dication for, 38 
Weight of infants, 28 
Wetnurses, selection of, 39 

communication of disease by, 45 
White softening of intestinal mucous 

membrane, 709 
Whooping-cough [see Pertussis). 
Worms, '765 

intestinal, as a cause of constipation, 

752 
as a cause of intussusception, 788 



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Also for sale separate — 
HOLDEN, LUTHEB, F. B. C. S., 

Surgeon to St. Bartholomew's and the Foundling Hospitals, London. 
Landmarks, Medical and Surgical. Second American from the latest revised 
English edition, with additions by W. W. Keen, M. D., Professor of Artistic Anatomy in 
the Pennsylvania Academy of the Fine Arts, formerly Lecturer on Anatomy in the Phila- 
delphia School of Anatomy. In one handsome 12mo. volume of 148 pages. Cloth, $1.00. 

This little book is all that can be desired within almost to learn it by heart. It teaches diagnosis by 

its scope, and its contents will be found simply in- external examination, ocular and palpable, of the 

valuable to the young surgeon or physician, since body, with such anatomical and physiological facts 

they bring before him such data as he requires at as directly bear on the subject. It is eminently 

every examination of a patient. It is written in the student's and young practitioner's book. — Phy- 

language so clear and concise that one ought sician and Surgeon, Nov. 1881. 



WILSON, EBASMUS, F. B. S. 

A System of Human Anatomy, General and Special. Edited by W. H. 
Gobrecht, M. D., Professor of General and Surgical Anatomy in the Medical College of 
Ohio. In one large and handsome octavo volume of 616 pages, with 397 illustrations. 
Cloth, $4.00 ; leather, $5.00. _____ 

SMITH, H. H., M. !>., and HOBNEB, W3I. F.,M.I>., 

Emeritus Prof, of Surgery in the Univ. of Penna., etc. Late Prof, of Anat. in the Univ. of Penna. 
An Anatomical Atlas, Illustrative of the Structure of the Human Body. In one 
large imperial octavo volume of 200 pages, with 634 beautiful figures. Cloth, $4.50. 

CLELAND, JOHN, M. !>., F. B. S., 

Professor of Anatomy and Physiology in Queen's College, Galway. 

A Directory for the Dissection of the Human Body. In one 12mo. 
volume of 178 pages. Cloth, $1.25. 



6 Lea Brothers & Co.'s Publications — Anatomy. 

ALLEN, HARRISON, 31. L>., 

Professor oj Physiology in the University of Pennsylvania. 

A System of Human Anatomy, Including Its Medical and Surgical 
Relations. For the use of Practitioners and Students of Medicine. With an Intro- 
ductory Section on Histology. By E. O. Shakespeare, M. IX, Ophthalmologist to 
the Philadelphia Hospital. Comprising 813 double-columned quarto pages, with 380 
illustrations on 109 full page lithographic plates, many of which are in colors, and 241 
engravings in the text. In six Sections, each in a portfolio. Section I. Histology. 
Section II. Bones and Joints. Section III. Muscles and Fasciae. Section IV. 
Arteries, Veins and Lymphatics. Section V. Nervous System. Section VI. 
Organs of Sense, of Digestion and Genito-Urinary Organs, Embryology, 
Development, Teratology, Superficial Anatomy, Post-Mortem Examinations, 
and General and Clinical Indexes. Price per Section, $3.50 ; also bound in one 
volume, cloth, $23.00 ; very handsome half Kussia, raised bands and open back, $25.00. 
For sale by subscription only. Apply to the Publishers. 

Extract from Introduction. 

It is the design of this book to present the facts of human anatomy in the manner best 
suited to the requirements of the student and the practitioner of medicine. The author 
believes that such a book is needed, inasmuch as no treatise, as far as he knows, contains, in 
addition to the text descriptive of the subject, a systematic presentation of such anatomical 
facts as can be applied to practice. 

A book which will be at once accurate in statement and concise in terms ; which will be 
an acceptable expression of the present state of the science of anatomy ; which will exclude 
nothing that can be made applicable to the medical art, and which will thus embrace all 
of surgical importance, while omitting nothing of value to clinical medicine, — would appear 
to have an excuse for existence in a country where most surgeons are general practitioners, 
and where there are few general practitioners who have no interest in surgery. 

It is to be considered a study of applied anatomy I care, and are simply superb. There is as much 
in its widest sense — a systematic presentation of | of practical application of anatomical points to 
such anatomical facts as can be applied to the I the every-day wants of the medical clinician as 
practice of medicine as well as of surgery. Our to those of the operating surgeon. In fact, few 
author is concise, accurate and practical in his general practitioners will read the work without a 
statements, and succeeds admirably in infusing feeling of surprised gratification that so many 
an interest into the study of what is generally con- points, concerning which they may never have 
sidered a dry subject. The department of Histol- ; thought before are so well presented" for their con- 
ogy is treated in a masterly manner, and the \ sideration. It is a work which is destined to be 
ground is travelled over by one thoroughly famil- ' the best of its kind in any language. — Medical 
far with it. The illustrations are made witn great | Record, Nov. 25, 1882. 



CLARKE, W. B., F.R. C.S. & LOCK WOOD, C. B., F.R. C.S. 

Demonstrators of Anatomy at St. Bartholomew's Hospital Medical School, London. 
The Dissector's Manual. In one pocket-size 12mo. volume of 396 pages, with 
49 illustrations. Limp cloth, red edges, $1.50. See Students' Series of Manuals, page 4. 

This is a very excellent manual for the use of the ] part, are good and instructive. The book is neat 
student who desires to learn anatomy. The meth- | and convenient. We are glad to recommend it. — 
ods of demonstration seem to us very satisfactory, j Boston Medical and Surgical Journal, Jan. 17, 1884. 
There are many woodcuts which, for the most I 

TREVES, FREDERICK, F. R. C. &, 

Senior Demonstrator of Anatomy and Assistant Surgeon at the London Hospital. 

Surgical Applied Anatomy. In one pocket-size 12mo. volume of 540 pages, 
with 61 illustrations. Limp cloth, red edges, $2.00. See Students^ Series of Manuals, 
page 4. 

He has produced a work which will command a I quickened by daily use as a teacher and practi- 
larger circle of readers than the class for which it tioner, has enabled our author to prepare a work 
was written. This union of a thorough, practical I which it would be a most difficult task to excel. — 
acquaintance with these fundamental branches, j The American Practitioner Feb. 1884. 

CURJSOW, JOHN, 31. D., F. R. C. P., 

Professor of Anatomy at King's College, Physician at King's College Hospital. 
Medical Applied Anatomy. In one pocket-size 12mo. volume. Preparing* 

See Students' Series of Manuals, page 4. 

BELLA3IY, EDWARD, F. R. C. S., 

Senior Assistant-Surgeon to the Charing-Cross Hospital, London. 

The Student's Guide to Surgical Anatomy : Being a Description of the 
most Important Surgical Eegions of the Human Body, and intended as an Introduction to 
operative Surgery. In one 12mo. volume of 300 pages, with 50 illustrations. Cloth, $2.25. 

HARTSHORNE'S HANDBOOK OF ANATOMY 1 HORNER'S SPECIAL ANATOMY AND HISTOL- 

AND PHYSIOLOGY. Second edition, revised. OGY. Eighth edition, extensively revised and 

In one royal 12mo. volume of 310 pages, with 220 J modified. In two octavo volumes of 1007 pages 

woodcuts. Cloth, $1.75. with 320 woodcuts. Cloth, $6.00. 



Lea Brothers & Co.'s Publications — Physics, Physiol., Anat. 



dbabeb, jomsr a, 3i. n., ll. id., 

Professor of Chemistry in the University of the City of New York. 

Medical Physics. A Text-book for Students and Practitioners of Medicine. In 
one octavo volume of 734 pages, with 370 woodcuts, mostly original, Cloth, §4. Just ready . 

Prom the Preface. 

The fact that a knowledge of Physics is indispensable to a thorough understanding of 
Medicine lias not been as fully realized in this country as in Europe, where the admirable 
works of Desplats and Gariel, of Robertson and of numerous German writers constitute a 
branch of educational literature to which we can show no parallel. A full appreciation 
of this the author trusts will be sufficient justification for placing in book form the sub- 
stance of his lectures on this department of science, delivered during many years at the 
University of the City of New York. 

Broadly speaking, this work aims to impart a knowledge of the relations existing 
between Physics and Medicine in their latest state of development, and to embody in the 
pursuit of this object whatever experience the author has gained during a long period of 
teaching this special branch of applied science. 

This elegant and useful work bears ample testi- j After these the special departments of physics are 
mony to the learning and good judgment of the ! explained, acoustics, optics, heat, electricity and 
author. He has fitted his work admirably to the magnetism, closing with a section on electro- 
exigencies of the situation by presenting the ' biology. The applications of all these to physiology 
reader with brief, clear and simple statements of and medicine are kept constantly in view. The 
such propositions as he is by necessity required to j text is amply illustrated and the many difficult 
master. The subject matter is well arranged, points of the subject are brought forward with re- 
liberally illustrated and carefully indexed. That j markable clearness and ability. — Medical and Surg- 
it will take rank at once among the text-books is ical Reporter, July 18, 1885. q. 
certain, and it is to be hoped that it will find a ! The volume from beginning to end teems with 
place upon the shelf of the practical physician, ; useful information. Take the book as a whole 
where, as a book of reference, it will be found | and it is one of the most valuable scientific 
useful and agreeable. — Louisville Medical News, treatises given to the medical profession for 



September 26, 1S85. 

Certainly we have no textbook as full as the ex- 
cellent one he has prepared. It begins with a 
■statement of the properties of matter and energy, 



number of years. It is profusely and handsomely 
illustrated. The work should have a place upon 
every physician's library shelf. — Maryland Medical 
Journal, July 18, 1885. q. 



MQBFjBTSOIT, J. McGBEGOB, M. A., M. B., 

Muirhead Demonstrator of Physiology, University of Glasgow. 
Physiological Physics. In one 12mo. volume of 537 pages, with 219 illustra- 
tions. Limp cloth, §2.00. See Students 7 Series of Manuals, page 4. 

The title of this work sufficiently explains the j ments. It will be found of great value to the 
nature of its contents. It is designed as a man- practitioner. It is a carefully prepared book of 
ual for the student of medicine, an auxiliary to reference, concise and accurate, and as such we 
his text-book in physiology, and it would be particu- ; heartily recommend it.— Journal of the American 
larly useful as a guide to his laboratory experi- | Medical Association, Dec. 6, 1884. 

nALTOF, josw a, m. n., 

Professor Emeritus of Physiology in the College of Physicians and Surgeons, New York. 

Doctrines of the Circulation of the Blood. A History of Physiological 
Opinion and Discovery in regard to the Circulation of the Blood. In one handsome 
12mo. volume of 293 pages. Cloth, $2. 

iJ^^S^Z^^^S^u^^^^^^ revolutionized the theories of teachers, than the 
'«L« ♦ V T f ^ ' a ° d to ^e. busy practitioner it . discovery of the circulation of the blood. This 
'£?£?;£• -fi a % OU ; r - Ce °l msi . r uction It will ! explains the extraordinary interest it has to all 
IS I IF Wlth i a , f « elln S of gratitute and admir- t medical histor&tar.. The volume before us is one 
'££« i ?JfK <? P^^mg workers of olden times, of three or four which have been written within a 
who laid the foundation of the magnificent temple few years by American physicians. It is in several 
of medical science as it now stands.— New Orleans ! respects the most complete. The volume, though 
Medical and Surgical Journal, Aug. 1885. small in size, is one of the most creditable con- 

in tne progress of physiological study no fact i tributions from an American pen to medical history 
was ol greater moment, none m ore completely that has appeared.— Med. & Surg. Rep., Dec. 6, 1884. 

^ELL, F. JEFFBEY, 31. A., 

Professor of Comparative Anatomy at King's College, London. 

^ Comparative Physiology and Anatomy. In one 12mo. volume of 561 pages, 
With 229 illustrations. Limp cloth, $2.00. See Students' Series of Manuals, page 4. 

This is another of the "Students' Series of j student of biology will be materially benefited by 
Manuals, and a most excellent one at that. The ; careful investigation of this valuable little work, 
descriptions are clear, the illustrations good, and I —Southern Practitioner, October, 1885. 
the presswork and paper unexceptionable. The | 



ELLIS, GEOBGE VIJ\EB, 

Emeritus Professor of Anatomy in University College, London. 

Demonstrations of Anatomy. Being a Guide to the Knowledge of the 
Human Body by Dissection. From the eighth and revised London edition. In one very 
handsome octavo volume of 716 pages, with 249 illustrations. Cloth, $4.25 ; leather, $5.25. 

BOBEBTS, JOHN B., A. M., M. JD. 9 

Prof, of Applied Anat. and Oper. Surg, in Phila. Polyclinic /id Coll. for Graduates in Medicine. 
The Compend of Anatomy. For use in the dissecting-room and in preparing 
for examinations. In .one 16mo. volume of 196 pages. Limp cloth, 75 cents. 



8 Lea Brothers & Co.'s Publications — Physiology, Chemistry. 



DALTOK, JOHN C, M. !>., 

Professor of Physiology in the College of Physicians and Surgeons, New York, etc. 

A Treatise on Human Physiology. Designed for the use of Students and 
Practitioners of Medicine. Seventh edition, thoroughly revised and reAvritten. In one 
very hands( me octavo volume of 722 pages, with 252 beautiful engravings on wood. Cloth, 
$5.00; leather, $6.00; very. handsome half Russia, raised bands, $6.50. 

The merits of Professor Dalton's text-book, his more compact form, yet its delightful charm is re- 
emooth and pleasing style, the remarkable clear- i tained, and no subject is thrown into obscurity, 
ness of his descriptions, which leave not a chapter j Altogether this edition is far in advance of any 
obscure, his cautious judgment and the general j previous one, and will tend to keep the profession 
correctness of his facts, are perfectly known. They | posted as to the most recent additions to our 
have made his text-book the one most familiar ' physiological knowledge. — Michigan Medical News, 



to American students. — Med. Record, March 4, 1882. 
Certainly no physiological work has ever issued 
from the press that presented its subject-matter in 
a clearer and more attractive light. Almost every 
page bears evidence of the exhaustive revision 
that has taken place. The material is placed in a 



April, 1882. 

One can scarcely open a college catalogue that 
does not have mention of Dalton's Physiology as 
the recommended text or consultation-book. For 
American students we would unreservedly recom- 
mend Dr. Dalton's work.- Va. Med. Monthly, July,'82. 



FOSTER, MICHAEL, M. D., F. B. S., 

Prelector in Physiology and Fellow of Trinity College, Cambridge, England. 
Text-Book of Physiology. Third American from the fourth English edition, 
with notes and additions by E. T. Reichert, M. D. In one handsome royal 12mo. volume 
of 908 pages, with 271 illustrations. Cloth, $3.25; leather, $3.75. Just ready. 



Dr. Foster's work upon physiology is so well- 
known as a text-book in this country, that it needs 
but little to be said in regard to it. There is 
scarcely a medical college in the United States 
where it is not in the hands of the students. The 
author, more than any other writer with whom 
we are acquainted, seems to understand what 
portions of the science are essential for students 



to know and what maybe passed over by them as 
not important. From the beginning to the end, 
physiology is taught in a systematic manner. To 
this third American edition numerous additions, 
corrections and alterations have been made, so 
that in its present form the usefulness of the book 
will be found to be much increased.— Cincinnati 
Medical Neivs, Julv 1885. 



POWEB, HENBY, M. B., F. B. C. S., 

Examiner in Physiology, Royal College of Surgeons of England. 
Human Physiology. In one handsome pocket-size 12mo. volume of 396 pages, 
with 47 illustrations. Cloth, $1.50. See Students' Series of Manuals, page 3. 



The prominent character of this work is that of 
judicious condensation, in which an able and suc- 
cessful effort appears to have been made by its 
accomplished author to teach the greatest number 
of facts in the iewest possible words. The result 
is a specimen of concentrated intellectual pabu- 
lum seldom surpassed, which ought to be care- 
fully ingested and digested by every practitioner 
who desires to keep himself well informed upon 
this most progressive of the medical sciences. 
The volume is one which we cordially recommend 



to every one of our readers. — The American Jour- 
nal of the Medical Sciences, October, 1884. 

This little work is deserving of the highest 
praise, and we can hardly conceive how the main 
facts of this science could have been more clearly 
or concisely stated. The price of the work is such 
as to place it within the reach of all, while the ex- 
cellence of its text will certainly secure for it most 
favorable commendation — Cincinnati Lancet and 
Clinic, Feb. 16, 1884. 



CABPEWTEB, WM. B., M. JD., F. B. S., F. G. 8., F. L. S., 

Registrar to the University of London, etc. 

Principles of Human Physiology. Edited by Henry Power, M. B., Lond., 
F. E. C. S., Examiner in Natural Sciences, University of Oxford. A new American from the 
eighth revised and enlarged edition, with notes and additions by Francis G. Smith, M. D., 
late Professor of the Institutes of Medicine in the University of Pennsylvania. In one 
very large and handsome octavo volume of 1083 pages, with two plates and 373 illus- 
trations. Cloth, $5.50 ; leather, $6.50 ; half Russia, $7. 



SIMON, W., Ph. D., M. I)., 

Professor of Chemistry and Toxicology in the College of Physicians and Surgeons, Baltimore, and 

Professor of Chemistry in the Maryland College of Pharmacy. 
Manual of Chemistry. A Guide to Lectures and Laboratory work for Beginners 
in Chemistry. A Text-book, specially adapted for Students of Pharmacy and Medicine. 
In one 8vo. vol. of 410 pp., with 16 woodcuts and 7 plates, mostly of actual deposits, 
with colors illustrating 56 of the most important chemical reactions. Cloth, $3.00 ; also 
without plates, cloth, $2.50. 



This book supplies a want long felt by students 
of medicine and pharmacy, and is a concise but 
thorough treatise on the subject. The long expe- 
rience of the author as a teacher in schools of 
medicine and pharmacy is conspicuous in the 
perfect adaptation of the work to the special needs 
of the student of these branches. The colored 



plates, beautifully executed, illustrating precipi- 
tates of various reactions, form a novel and valu- 
able feature of the book, and cannot fail to be ap- 
preciated by both student and teacher as a help 
over the hard places of the science.— Maryland 
Medical Journal, Nov. 22, 1884. 



Wohler's Outlines of Organic Chemistry. Edited by Fittig. Translated 
by Ira Remsen, M. D., Ph. D. In one 12mo. volume of 550 pages. Cloth, $3. 



GALLOWAY'S QUALITATIVE ANALYSIS. 

LEHM ANN'S MANUAL OF CHEMICAL PHYS- 
IOLOGY. In one octavo volume of 327 pages, 
with 41 illustrations. Cloth, $2.25. 



CARPENTER'S PRIZE ESSAY ON THE USE AND 
Abuse or Alcoholic Liqdoks in Health and Dis- 
ease, With explanations of scientific words. Small 
12mo. 178 pages. Cloth, 60 cents. 



Lea Brothers & Co.'s Publications — Chemistry. 



9 



FOWNES, GEORGE, Fh. 2>. 

A Manual of Elementary Chemistry; Theoretical and Practical. Em- 
bodying Watts' Inorganic Chemistry. New American edition. In one large royal 12mo. 
volume of 1061 pages, with 168 illustrations on wood and a colored plate. Cloth, $2.75; 
leather, §3.25. Just ready. 

Fownes 1 Chemistry has been a standard text- | work as one of the very best text-books upon 
book upon chemistry for many years. Its merits j chemistry extant. — Cincinnati Medical News, Oc- 
are very fully known by chemists and physicians tober, 1885. 

everywhere in this country and in England. As More than a quarter of a century ago thi3 stan- 
the science has advanced by the making of new dard and reliable textbook was placed in our 
discoveries, the work has been revised so as to hands. Since then eleven successive editions 
keep it abreast of the times. It has steaiily have appeared, and during the interval it has 
maintained its position as a text book with medi- , held, undisputed and unquestioned, its place as a 
cal students. In this work are treated fully: Heat, text-book in the most reliable and reputable in- 
Light and Electricity, including Magnetism. The stitutions of medical learning in America. A 
influence exerted by these forces in chemical ' brief and somewhat cursory examination satisfies 
action upon health and disease, etc., is of the most us that the last edition is more deserving of 
important kind, and should be familiar to every , commendation than any that have preceded it. 
medical practitioner. We can commend the I — Southern Practitioner, November, 1885 . 

FRANKLAND, E., 2>. C.L.,F.R.S. 9 &JAFF, F. R., F. I. C, 



Professor of Chemistry in the Normal School 
of Science, London. 



Assist. Prof, of Chemistry in the Normal 
School of Science, London. 



Inorganic Chemistry. In one handsome octavo volume of 677 pages with 51 
woodcuts and 2 lithographic plates. Cloth, $3.75 ; leather, $4.75. Just ready. 

This work on elementary chemistry is based upon principles of classification, nomen- 
clature and notation which have been proved by nearly twenty years' experience in teach- 
ing to impart most readily a sound and accurate knowledge of the science. 



ATTFIELI), JOJELN, Fh. J>. 9 

Professor of Practical Chemistry to the Pharmaceutical Society of Great Britain, etc. 

Chemistry, General, Medical and Pharmaceutical; Including the Chem- 
istry of the U. S. Pharmacopoeia. A Manual of the General Principles of the Science, 
and their Application to Medicine and Pharmacy. A new American, from the tenth 
English edition, specially revised by the Author. In one handsome royal 12mo. volume 
of 728 pages, with 87 illustrations. Cloth, $2.50 ; leather, $3.00. 



A text-book which passes through ten editions 
in sixteen years must have good qualities. This 
remark is certainly applicable to Attfield's Chem- 
istry, a book which i3 so well known that it is 
hardly necessary to do more than note the appear- 
ance of this new and improved edition. It seems, 
however, desirable to point out that feature of the 
book which, in all probability, has made it so 
popular. There can be little doubt that it is its 
thoroughly practical character, the expression 
being used in its best sense. The author under- 
stands what the student ought to learn, and is able 



to put himself in the student's place and to appre- 
ciate his state of mind. — American Chemical Jour- 
nal, April, 1884. 

It is a book on which too much praise cannot be 
bestowed. A3 a text-book for medical schools it 
is unsurpassable in the present state of chemical 
science, and having been prepared with a special 
view towards medicine and pharmacy, it is alike 
indispensable to all persons engaged in those de- 
partments of science. It includes the whole 
chemistry of the last Pharmacopoeia. — Pacific Medi- 
cal and Sugrical Journal, Jan. 1884. 



BLOXAM, CHARLES L., 

Professor of Chemistry in King's College, London. 

Chemistry, Inorganic and Organic. Xew American from the fifth Lon- 
don edition, thoroughly revised and much improved. In one very handsome octavo 
volume of 727 pages, with 292 illustrations. Cloth, $3.75 ; leather, $4.75. 

Comment from us on this standard work is al- j maintains the position it has always held as one'of 
most superfluous. It differs widely in scope and ! the best manuals of general chemistry in the Eng- 



aim from that of Attfield, and in its way is equally 
beyond criticism. It adopts the most direct meth- 
ods in stating the principles, hypotheses and facts 
of the science. Its language is so terse and lucid, 
and its arrangement of matter so logical in se- 
quence that the student never has occasion to 
complain that chemistry is a hard study. Much 
attention is paid to experimental illustrations of 
chemical principles and phenomena, and the 
mode of conducting these experiments. The book 



lish language. — Detroit Lancet, Feb. 1884. 

The evident object is to give clear and concise 
descriptions of all known elements and of their 
most important compounds, with explanations 
of the chemical laws and principles involved. 
We gladly repeat now the opinion we expressed 
about a former edition, that we regard Bloxam's 
Chemistry as one ot the best treatises on general 
and applied chemistry. — American Jour, of Phar- 
macy, Dec. 1883. 



RE31SEJT, IRA, 31. B. 9 Fh. B. 9 

Professor of Chemistry in the Johns Hopkins University, Baltimore. 

Principles of Theoretical Chemistry, with special reference to the Constitu- 
tion of Chemical Compounds. Second and revised edition. In one handsome royal 12mo. 
volume of 240 pages. Cloth, $1.75. Just ready. 

That in so few years a second edition has ! assures its accuracy in all matters of fact, and its 
been called for indicates that many chemical judicious conservatism in matters of theory, corn- 
teachers have been found ready to endorse its : bined with the fulness with which, in a small 
plan and to adopt its methods. In this edition compass, the present attitude of chemical science 
a considerable proportion of the book has been towards the constitution of compounds is con- 
rewritten, much new matter has been added j sidered, gives it a value much beyond that accorded 
and the whole has been brought up to date. ! to the average text-books of the day. — American 
We earnestly commend this book to every student i Journal of Science, March, 1884. 
of chemistry. The high reputation of the author | 



10 



Lea Brothers & Co.'s Publications — Chemistry. 



CHARLES, T. CRANSTOVJST, 31. D., F. C. S., M. S., 

Formerly Asst. Prof, and Dcmonst. of Chemistry and Chemical Physics, Queen's College, Belfast. 

The Elements of Physiological and Pathological Chemistry. A 

Handbook for Medical Students and Practitioners. Containing a general account of 
Nutrition, Foods and Digestion, and the Chemistry of the Tissues, Organs, Secretions and 
Excretions of the Body in Health and in Disease. Together with the methods for pre- 
paring or separating their chief constituents, as also for their examination in detail, and 
an outline syllabus of a practical course of instruction for students. In one handsome octavo 
volume of 463 pages, with 38 woodcuts and 1 colored plate. Cloth, $3.50. 

Dr. Charles' manual admirably fulfils its inten- 



The work is thoroughly trustworthy, and in- 
formed throughout by a genuine scientific spirit. 
The author deals with the chemistry of the diges- 
tive secretions in a systematic manner, which 
leaves nothing to be desired, and in reality sup- 
plies a want in English literature. The book ap- 
pears to us to be at once full and systematic, and 
to show a just appreciation of the relative import- 
ance of the various subjects dealt with. — British 
Medical Journal, November 29, 1884. 



tion of giving his readers on the one hand a sum- 
mary, comprehensive but remarkably compact, of 
the mass of facts in the sciences which have be- 
come indispensable to the physician ; and, on the 
other hand, of a system of practical directions so 
minute that analyses often considered formidable 
may be pursued by any intelligent person. — 
Archives of Medicine, Dec. 1884. 



HOFFMAJSN, F., A.3I., Fh.D., & POWER F.B., Ph.D., 

Public Analyst to the State of New York. Prof, of Anal. Chem. in the Phil. Coll. of Pharmacy. 

A Manual of Chemical Analysis, as applied to the Examination of Medicinal 
Chemicals and their Preparations. Being a Guide for the Determination of their Identity 
and Quality, and for the Detection of Impurities and Adulterations. For the use of 
Pharmacists, Physicians, Druggists and Manufacturing Chemists, and Pharmaceutical and 
Medical Students. Third edition, entirely rewritten and much enlarged. In one very 
handsome octavo volume of 621 pages, with 179 illustrations. Cloth, $4.25. 



We congratulate the author on the appearance 
of the third edition of this work, published for the 
first time in this country also. It is admirable and 
the information it undertakes to supply is both 
extensive and trustworthy. The selection of pro- 
cesses for determining the purity of the substan- 
ces of which it treats is excellent and the descrip- 



tion of them singularly explicit. Moreover, it is 
exceptionally free from typographical errors. We 
have no hesitation in recommending it to those 
who are engaged either in the manufacture or the 
testing of medicinal chemicals. — London Pharma' 
ceutical Journal and Transactions, 1883. 



CLOWES, FRAJSK, I). Sc, London, 

Senior Science- Master at the High School, Newcastle-under-Lyme, etc. 

An Elementary Treatise on Practical Chemistry and Qualitative 
Inorganic Analysis. Specially adapted for use in the Laboratories of Schools and 
Colleges and by Beginners. Third American from the fourth and revised English edition. 
In one very handsome royal 12mo. volume of 387 pages, with 55 illustrations. Cloth, 

$2.50. Just ready. 



The style is clear, the language terse and vigor- 
ous. Beginning with a list of apparatus necessary 
for chemical work, he gradually unfolds the sub- 
ject from its simpler to its more complex divisions. 
It is the most readable book of the kind we have 
yet seen, and is without doubt a systematic, 
intelligible and fully equipped laboratory guide 



and text book. — Medical Record, July 18, 1885. 

We may simply repeat the favorable opinion 
which we expressed after the examination of the 
previous edition of this work. It is practical in its 
aims, and accurate and concise in its statements. 
— American Journal of Pharmacy, August, 1885. 



RALFB, CHARLES H., 31. D., F. R. C. P., 

Assistant Physician at the London Hospital. 

Clinical Chemistry. In one pocket-size 12mo. volume of 314 pages, with 16 



illustrations. Limp cloth, red edges, $1.50, 
This is one of the most instructive little works 
that we have met with in a long time. The author 
is a physician and physiologist, as well as a chem- 
ist, consequently the book is unqualifiedly prac- 
tical, telling the physician just what he ought to 
know, of the applications of chemistry in medi- 



See Students' Series of Manuals, page 4. 
cine. Dr. Ralfe is thoroughly acquainted with the 
latest contributions to his science, and it is quite 
refreshing to find the subject dealt with so clearly 
and simply, yet in such evident harmony with the 
modern scientific methods and spirit. — Medical 
Record, February 2, 1884. 



CLASSEN, ALEXANDER, 

Professor in the Royal Polytechnic School, Aix-la- CJiapelle. 

Elementary Quantitative Analysis. Translated, with notes and additions, by 
Edgar F. Smith, Ph. D., Assistant Professor of Chemistry in the Towne Scientific School, 
University of Penna. In one 12mo. volume of 324 pages, with 36 illust. Cloth, $2.00. 

It is probably the best manual of an elementary and then advancing to the analysis of minerals and 
nature extant insomuch as its methods are the such products as are met with in applied chemis- 
best. It leaches by examples, commencing with try. It is an indispensable book for students in 
single determinations, followed by separations, chemistry. — Boston Journal of Chemistry, Oct. 1878. 



GREENE, W1LLIA3L H., 31. L>., 

Demonstrator oj Chemistry in the Medical Department of the University of Pennsylvania. 
A Manual of Medical Chemistry. For the use of Students. Based upon Bow- 
man's Medical Chemistry. In one 12mo. volume of 310 pages, with 74 illus. Cloth, $1.75. 
It is a concise manual of three hundred pages, the recognition of compounds due to pathological 
giving an excellent summary of the best methods conditions. The detection of poisons is treated 
of analyzing the liquids and solids of the body, both with sufficient fulness for the purpose of thestu- 
or the estimation of their normal constituents and dent or practitioner. — Boston Jl. of Chem., June, '80. 



Lea Brothers & Co.'s Publications — Pharm., Mat. Med., Therap. 11 
BBTJNTOW, T. LATJDBR, M.D., D.Sc, F.B.S., F.B.C.P., 

Lecturer on Materia Medica and Therapeutics at St. Bartholomeio's Hospital, London, etc. 

A Text-book of Pharmacology, Therapeutics and Materia Medica; 

Including the Pharmacy, the Physiological Action and the Therapeutical Uses of Drugs. 
In one handsome octavo volume of 1033 pages, with 188 illustrations. Cloth, $5.50 ; 
leather, $6.50. Just ready. 

It is with peculiar pleasure that the appearance of this long expected work is 
announced by the publishers. Written by the foremost authority on its subject in Eng- 
land, it forms a compendious treatise on materia medica, pharmacology, pharmacy, and 
the practical use of medicines in the treatment of disease. Space has been devoted to the 
fundamental sciences of chemistry, physiology and pathology, wherever it seemed necessary 
to elucidate the proper subject-matter of the book. A general index, an index of diseases 
and remedies, and an index of bibliography close a volume which will undoubtedly be of 
the highest value to the student, practitioner and pharmacist. 



It is a scientific treatise worthy to be ranked with 
the highest productions in physiology, either in 
our own or any other language. Everything is 
practical, the dry, hard facts of physiology being 
pressed into service and applied to the treatment 
■of the commonest complaints. The information 
is so systematically arranged that it is available 
for immediate use. The index is so carefully 



compiled that a reference to any special point is 
at once obtainable. Dr. Brunton is never satisfied 
with vague generalities, but gives clear and pre- 
cise directions for prescribing the various drugs 
and preparations. We congratulate students on 
being at last placed in possession of a scientific 
treatise of enormous practical importance. — The 
London Lancet, June 27, 1885. 



PAKKISH, FDWABD, 

Late Professor of the Theory and Practice of Pharmacy in the Philadelphia College of Pharmacy. 
A Treatise on Pharmacy : designed as a Text-book for the Student, and as a 
Ouide for the Physician and Pharmaceutist. With many Formulae and Prescriptions. 
Fifth edition, thoroughly revised, by Thomas S. Wiegand, Ph. G. In one handsome 
octavo volume of 1093 pages, with 256 illustrations. Cloth, $5 ; leather, $6. 

No thoroughgoing pharmacist will fail to possess I Each page bears evidence of the care bestowed 
himself of so useful a guide to practice, and no ] upon it, and conveys valuable information from 
physician who properly estimates the value of an ■ the rich store of the editor's experience. In fact, 
Accurate knowledge of the remedial agents em- i all that relates to practical pharmacy— apparatus, 
ployed by him in daily practice, so far as their j processes and dispensing— has been arranged and 
miscibility, compatibility and most effective meth- j described with clearness in its various aspects, so 
•ods of combination are concerned, can afford to ; as to afford aid and advice alike to the student and 
leave this work out of the list of their works of < to the practical pharmacist. The work is judi- 
reference. The country practitioner, who must ; ciously illustrated with good woodcuts — American 
always be in a measure his own pharmacist, will Journal of Pharmacy, January, 1884. 
-find " it indispensable. — Louisville Medical News, There is nothing to equal Parrish's Pharmacy 
March 29, 1884. in this or any other language.— London Pharma- 

This well-known work presents itself now based I ceutical Journal. 
upon the recently revised new Pharmacopoeia. | 

MJEUMAJSnsr, Dr. L^ 

Professor of Physiology in the University of Zurich. 

Experimental Pharmacology. A Handbook of Methods for Determining the 
Physiological Actions of Drugs. Translated, with the Author's permission, and with 
extensive additions, by Robert Meade Smith, M. D., Demonstrator of Physiology in the 
University of Pennsylvania. In one handsome 12mo. volume of 199 pages, with 32 
illustrations. Cloth, $1.50. 

MAIS CS f JOHNM., JPhar. D., 

Professor of Materia Medica and Botany in the Philadelphia College of Pharmacy. 

A Manual of Organic Materia Medica; Being a Guide to Materia Medica of 
the Vegetable and Animal Kingdoms. For the use of Students, Druggists, Pharmacists 
and Physicians. New (second) edition. In one handsome royal 12mo. volume of 526 
pages, with 242 illustrations. Cloth, $3.00. 



excellent, being very true to nature, and are alone 
worth the price of the book to the student. To the 
practical physician and pharmacist it is a valuable 
work for handy reference and for keeping fresh 
in the memory the knowledge of materia medica 
and botany already acquired. We can and do 
heartily recommend it.— Medical and Surgical Re- 



This work contains the substance, — the practical 
"kernel of the nut" picked out, so that the stu- 
dent has no superfluous labor. He can confidently 
accept what this work places before him, without 
any fear that the gist of the matter is not in it. 
Another merit is that the drugs are placed before 
him in such a manner as to simplify very much 

the study of them, enabling the mind to grasp porter, "Feb. 14, 1885 
them more readily. The illustrations are most | 

BRUCE, J. MITCHELL, M. JD., F. B. C. P., 

Physician and Lecturer on Materia Medica and Therapeutics at Charing Cross Hospital, London. 
Materia Medica and Therapeutics. An Introduction to Kational Treat- 
ment. In one pocket-size 12mo. volume of 555 pages. Limp cloth, $1.50. See Students' 
Series of Manuals, page 4. 

GRIFFITH, ROBERT EGLESFIELD, M. JD. 

A Universal Formulary, containing the Methods of Preparing and Adminis- 
tering Officinal and other Medicines. The whole adapted to Physicians and Pharmaceut- 
ists. Third edition, thoroughly revised, with numerous additions, by John M. Maisch, 
Phar. D., Professor of Materia Medica and Botany in the Philadelphia College of Pharmacy. 
In one octavo volume of 775 pages, with 38 illustrations. Cloth, $4.50 ; leather, $5.50. 



12 Lea Brothers & Co.'s Publications — Mat. Med., Therap. 
STILLE, A., M. JD., LL. D., & MAISCH, J. 31., Phar. JD. 9 

Professor Emeritus of the Theory and Prac- Prof, of Mat. Med. and Botany in Phila. 

tice of Medicine and of Clinical Medicine College of Pharm an/, Sec\ij to the Ameri- 

in the University of Pennsylvania. can Pharmaceutical Association. 

The National Dispensatory: Containing the Natural History, Chemistry, Phar- 
macy, Actions and Uses of Medicines, including those recognized in the Pharmacopoeias of 
the United States, Great Britain and Germany, with numerous references to the French 
Codex. Third edition, thoroughly revised and greatly enlarged. In one magnificent 
imperial octavo volume of 1767 pages, with 311 tine engravings. Cloth, $7.25; 
leather, $8.00; half Kussia, open back, $9.00. With Denison's "Heady Keference Index" 
$1.00 in addition to price in any of above styles of binding. 

In the present revision the authors have labored incessantly with the view of making 
the third edition of The National, Dispensatory an even more complete represen- 
tative of the pharmaceutical and therapeutic science of 1884 than its first edition was of 
that of 1879. For this, ample material has been afforded not only by the new United 
States Pharmacopoeia, but by those of Germany and France, which have recently appeared 
and have been incorporated in the Dispensatory, together with a large number of new non- 
officinal remedies. It is thus rendered the representative of the most advanced state of 
American, English, French and German pharmacology and therapeutics. The vast amount 
of new and important material thus introduced may be gathered from the fact that the 
additions to this edition amount in themselves to the matter of an ordinary full-sized octavo 
volume, rendering the work larger by twenty-five per cent, than the last edition. The 
Therapeutic Index (a feature peculiar to this work), so suggestive and convenient to the 
practitioner, contains 1600 more references than the last edition — the General Index 
3700 more, making the total number of references 22,390, while the list of illustrations 
has been increased by 80. Every effort has been made to prevent undue enlargement of 
the volume by having in it nothing that could be regarded as superfluous, yet care has 
been taken that nothing should be omitted which a pharmacist or physician could expect 
to find in it. 

The appearance of the work has been delayed by nearly a year in consequence of the 
determination of the authors that it should attain as near an approach to absolute ac- 
curacy as is humanly possible. With this view an elaborate and laborious series of 
examinations and tests have been made to verify or correct the statements of the Pharma- 
copoeia, and very numerous corrections have been found necessary. It has thus been ren- 
dered indispensable to all who consult the Pharmacopoeia. 

The work is therefore presented in the full expectation that it will maintain the 
position universally accorded to it as the standard authority in all matters pertaining to 
its subject, as registering the furthest advance of the science of the day, and as embody- 
ing in a shape for convenient reference the recorded results of human experience in the 
laboratory, in the dispensing room, and at the bed-side. 

Comprehensive in scope, vast in design and 
ilendid in execution, The National Disj 



splendid in execution, The National Dispensator 
may be justly regarded as the most important* ork 
of its kind extant. — Louisville Medical News, Dec. 
6, 1884. 

We have much pleasure in recording the appear- 
ance of a third edition of this excellent work of 
reference. It is an admirable abstract of all that 
relates to chemistry, pharmacy, materia medica, 
pharmacology and therapeutics. It may be re- 
garded as embodying the Pharmacopoeias of the 
civilized nations of the world, all being brought 



up to date. The work has been very well done, a 
large number of extra-pharmacopceial remedies 
having been added to those mentioned in previous 
editions. — London Lancet, Nov. 22, 1884. 

Its completeness as to subjects, the comprehen- 
siveness of its descriptive language, the thorough- 
ness of the treatment of the topics, its brevity not 
sacrificing the desirable features of information 
for which such a work is needed, make this vol- 
ume a marvel of excellence. — Pharmaceutical Re- 
cord, Aug. 15, 1884. 



FARQVH ARSON, ROBERT, 31. J)., 

Lecturer on Materia Medica at St. Mary's Hospital Medical School. 

A Guide to Therapeutics and Materia Medica. Third American edition, 
specially revised by the Author. Enlarged and adapted to the U. S. Pharmacopoeia by 
Frank Woodbury, M. D. In one handsome 12mo. volume of 524 pages. Cloth, $2.25. 
Dr. Farquharson's Therapeutics is constructed I umned pages — one side containing the recognized 
upon a plan which brings before the reader all the physiological action of the medicine, and the other 
essential points with reference to the properties of j the disease in which observers (who are nearly al- 
ways mentioned) have ohtained from it good re- 
sults — make a very good arrangement. The early 



drugs. It impresses these upon him in such away 
as to enable him to take a clear view of the actions 
of medicines and the disordered conditions in 
which they must prove useful. The double-col- 



chapter containing rules for prescribing is excel- 
lent. — Canada Med. and Surg. Journal, Dec. 1882. 



STILLE, ALFRED, 31. D., EL. L>., 

Professor of Theory and Practice of Med. and of Clinical Med. in the Univ. of Penna. 
Therapeutics and Materia Medica. A Systematic Treatise on the Action and 
Uses of Medicinal Agents, including their Description and History. Fourth edition, 
revised and enlarged. In two large and handsome octavo volumes, containing 1936 pages. 
Cloth, $10.00; leather, $12.00; very handsome halt Russia, raised bands, $13.00. 

We can hardly admit that it has a rival in the 
multitude of its citation^ and the fulness of its 
research into clinical histories, and we must assign 
it a place in the physician's library; not, indeed, 
as fully representin g the present state of knowledge 



in pharmacodynamics, but as by far the most com- 
plete treatise upon the clinical and practical side 
of the question. — Boston Medical and Surgical Jour- 
nal, Nov. 5, 1874. 



Lea Brothers & Co.'s Publications — Pathol., Histol. 



13 



COATS, JOSEPH, M. D., F. JB. JP. S., 

Pathologist to the Glasgow Western Infirmary. 
A Treatise on Pathology. In one very handsome octavo volume of 829 pages, 
with 339 beautiful illustrations. Cloth, $5.50 ; leather, $6.50. 

The work before us treats the subject of Path- 
ology more extensively than it is usually treated 
in similar works. Medical students as well as 



physicians, who desire a work for study or refer- 
ence, that treats the subjects in the various de- 
partments in a very thorough manner, but without 
prolixity, will certainly give this one the prefer- 
ence to any with which we are acquainted. It sets 
forth the most recent discoveries, exhibits, in an 
interesting manner, the changes from a normal 



condition effected in structures by disease, and 
points out the characteristics of various morbid 
agencies, so that they can be easily recognized. But, 
not limited to morbid anatomy, it explains fully how 
the functions of organs are disturbed by abnormal 
conditions. There is nothing belonging to its de- 
partment of medicine that is not as fully elucidated 
as our present knowledge will admit. — Cincinnati 
Medical News, Oct. 1883. 



GREEN, T. HENRY, M. D., 

Lecturer on Pathology and Morbid Anatomy at Charing-Cross Hospital Medical School, London. 

Pathology and Morbid Anatomy. Fifth American from the sixth revised 
and enlarged English edition, in one very handsome octavo volume of 482 pages, with 
150 fine engravings. Cloth, $2.50. 



The fact that this well-known treatise has so 
rapidly reached its sixth edition is a strong evi- 
dence of its popularity. The author is to be con- 
gratulated upon the thoroughness with which he 
has prepared this work. It is thoroughly abreast 
with all the most recent advances in pathology. 



No work in the English language is so admirably 
adapted to the wants of the student and practi- 
tioner as this, and we would recommend it most 
earnestly to every one. — Nashville Journal of Medi- 
cine and Surgery, Nov. 1884. 



E., 



WOODHEAD, G. SIMS, M. D., F. B. C. JP. 

Demonstrator of Pathology in the University of Edinburgh. 
Practical Pathology. A Manual for Students and Practitioners. In one beau- 
tiful octavo volume of 497 pages, with 136 exquisitely colored illustrations. Cloth, $6.00. 

themselves with this manual. The numerous 
drawings are not fancied pictures, or merely 
schematic diagrams, but they represent faithfully 



It forms a real guide for the student and practi- 
tioner who is thoroughly in earnest in his en- 
deavor to see for himself and do for himself. To 
the laboratory student it will be a helpful com- 

fianion, and all those who may wish to familiarize 
hemselves with modern methods of examining 
morbid tissues are strongly urged to provide 



the actual images seen under the microscope. 
The author merits all praise for having produced 
a valuable work. — Medical Record, May 31, 1884. 



SCHAFER, EDWARD A., F. R. S., 

Assistant Professor of Physiology in University College, London. 

The Essentials of Histology. In one octavo volume of 246 pages, with 
281 illustrations. Cloth, $2.25. Just ready. 
Every physician and medical student having a 
microscope, on examining this work, would not 
think of doing without it, for it has been prepared 
by an author, who is a distinguished microscopist, 
with the object of supplying the student with di- 



rections for the microscopical examination of the 
tissues. At the same time it is intended to serve 
as an elementary text-hook of histology, com- 
prising all the essential facts of the science. — ■ 
Cincinnati. Medical News, Oct. 1885. 



CORNIL, V., and RANVIER, L., 

Prof, in the Faculty of Med. of Paris. Prof, in the College of France. 

A Manual of Pathological Histology. Translated, with notes and additions, 
by E. O. Shakespeare, M. D., Pathologist and Ophthalmic Surgeon to Philadelphia 
Hospital, and by J. Henry C. Simes, M. D., Demonstrator of Pathological Histology in 
the University of Pennsylvania. In one very handsome octavo volume of 800 pages, with 
360 illustrations. Cloth, $5.50 ; leather, $6.50 ; half Russia, raised bands, $7. 



KLEIN, E., M. D., F. R. S., 

Joint Lecturer on General Anat. and Phys. in the Med. School of St. Bartholomew's Hosp., London. 
Elements of Histology. In one pocket-size 12mo. volume of 360 pages, with 181 
illus. Li p cloth, red edges, $1.50. See Students' Series of Manuals, page 4. 

Although an elementary work, it is by no means 
superficial or incomplete, for the author presents 
in concise language nearly all the fundamental facts 
regarding the microscopic structure of tissues. 



The illustrations are numerous and excellent. We 
commend Dr. Klein's Elements most heartily to 
the student. — Medical Record, Dec. 1, 1883. 



FEFFER, A. J., 31. R., M. S., F. R. C. S., 

Surgeon and Lecturer at St. Mary's Hospital, London. 
Surgical Pathology. In one pocket-size 12mo. volume of 511 pages, with 81 
illustrations. Limp cloth, red edges, $2.00. See Students' Series of Manuals, page 4. 



It is not pretentious, but it will serve exceed- 
ingly well as a book of reference. It embodies a 
great deal of matter, extending over the whole 
field of surgical pathology. Its form is practical, 
its language is clear, and the information set 
forth is well-arranged, well-indexed and well- 



illustrated. The student will find in it nothing 
that is unnecessary. The list of subjects covers 
the whole range of surgery. The book supplies a 
very manifest want and should meet with suc- 
cess. — New York Medical Journal, May 31, 1884. 



LUGE'S ATLAS OF PATHOLOGICAL H1STOL- I copper-plate figures, plain and colored and des- 
OGY. .Translated by Joseph Leidy, M. D. In one criptive letter-press. Cloth, $4.00., 
volume, very large imperial quarto, with 320 | 



14 



Lea Brothers & Co.'s Publications — Practice of Med. 



FLINT, AUSTIN, M. JD., 

Prof, of the Principles and Practice of Med. and of Clin. Med. in Bellevue Hospital Medical College, N. T. 

A Treatise on the Principles and Practice of Medicine. Designed for 
the use of Students and Practitioners of Medicine. With an Appendix on the Researches 
of Koch, and their bearing on the Etiology, Pathology, Diagnosis and Treatment of 
Phthisis. Fifth edition, revised and largely rewritten In one large and closely-printed 
octavo volume of 1160 pages. Cloth, $5.50; leather, $6.50; half Russia, $7. 

Koch's discovery of the bacillus of tubercle gives promise of being the greatest 
boon ever conferred by science on humanity, surpassing even vaccination in its benefits to 
mankind. In the appendix to his work, Professor Flint deals with the subject from a 
practical standpoint, discussing its bearings on the etiology, pathology, diagnosis, prog- 
nosis and treatment of pulmonary phthisis. Thus enlarged and completed, this standard 
work will be more than ever a necessity to the physician who duly appreciates the re- 
sponsibility of his calling. 



A well-known writer and lecturer on medicine 
recently expressed an opinion, in the highest de- 

gree complimentary of the admirable treatise of 
>r. Flint, and in eulogizing it, he described it ac- 
curately as "readable and reliable." No textbook 
is more calculated to enchain the interest of the 
student, and none better classifies the multitudi- 
nous subjects included in it. It has already so far 
won its way in England, that no inconsiderable 
number of men use it alone in the study of pure 
medicine ; and we can say of it that it is in every 
way adapted to serve, not only as a complete guide, 
but also as an ample instructor in the science and 
practice of medicine. The style of Dr. Flint is 
always polished and engaging. The work abounds 
in perspicuous explanation, and is a most valuable 
text-book of medicine. — London Medical News. 



This work is so widely known and accepted as 
the best American text-book of the practice of 
medicine that it would seem hardly worth while to 
give this, the fifth edition, anything more than a 
passing notice. But even the most cursory exami- 
nation shows that it is, practically, much more 
than a revised edition; it is, in fact, rather a new 
work throughout. This treatise will undoubtedly 
continue to hold the first place in the estimation 
of American physicians and students. No one of 
our medical writers approaches Professor Flint in 
clearness of diction, breadth of view, and, what we 
regard of transcendent importance, rational esti- 
mate of the value of remedial agents. It is thor- 
oughly practical, therefore pre-eminently the book 
for American readers. — St. Louis Clin. Bee, Mar. '81. 



HABTSJEEOBNE, HFNBT, M. !>., II. !>., 

Lately Professor of Hygiene in the University of Pennsylvania. 

Essentials of the Principles and Practice of Medicine. A Handbook 
for Students and Practitioners. Fifth edition, thoroughly revised and rewritten. In one 
royal 12mo. volume of 669 pages, with 144 illustrations. Cloth, $2.75 ; half bound, $3.00. 



Within the compass of 600 pages it treats of the 
history of medicine, general pathology, general 
symptomatology, and physical diagnosis (including 
laryngoscope, ophthalmoscope, etc.), general ther- 
apeutics, nosology, and special pathology and prac- 
tice. There is a wonderful amount of information 
contained in this work, and it is one of the best 
of its kind that we have seen. — Glasgow Medical 
Journal, Nov. 1882. 

An indispensable book. No work ever exhibited 
a better average of actual practical treatment than 



this one ; and probably not one writer in our day 
had a better opportunity than Dr. Hartshorne for 
condensing all the views of eminent practitioners 
into a 12mo. The numerous illustrations will be 
very useful to students especially. These essen- 
tials, as the name suggests, are not intended to 
supersede the text-books of Flint and Bartholow, 
but they are the most valuable in affording the 
means to see at a glance the whole literature of any 
disease, and the most valuable treatment. — Chicago 
Medical Journal and Examiner, April, 1882. 



BBISTOWF, JOHN STUB, M. D., F. B. C. P., 

Physician and Joint Lecturer on Medicine at St. Thomas' Hospital. 

A Treatise on the Practice of Medicine. Second American edition, revised 
by the Author. Edited, with additions, by James H. Hutchinson, M.D., physician to the 
Pennsylvania Hospital. In one handsome octavo volume of 1085 pages, with illustrations. 
Cloth, $5.00 ; leather, $6.00 ; very handsome half Kussia, raised bands, $6.50. 

The reader will find every conceivable subject are appropriate and practical, and greatly add to 

connected with the practice of medicine ably pre- its usefulness to American readers.— Buffalo Med- 

sented, in a style at once clear, interesting and ical and Surgical Journal, March, 1880. 
concise. The additions made by Dr. Hutchinson 



WATSON, SIB THOMAS, M. !>., 

Late Physician in Ordinary to the Queen. 

Lectures on the Principles and Practice of Physic. A new American 
from the fifth English edition. Edited, with additions, and 190 illustrations, by Henry 
Hartshorne, A. M., M. D., late Professor of Hygiene in the University of Pennsylvania, 
In two large octavo volumes of 1840 pages. Cloth, $9.00 ; leather, $11.00. 



LECTURES ON THE STUDY OF FEVER. By 
A. Hudson, M. D., M. R. I. A. In one oc tavo 
volume of 308 pages. Cloth, $2.50. 

STOKES' LECTURES ON FEVER. Edited by 
John William Moore, M. D., F. K. Q. C. P. In 
one octavo volume of 280 pages. Cloth, $2.00. 



A TREATISE ON FEVER. By Robeet D. Lyons, 
K. C. C. In one 8vo. vol. of 354 pp. Cloth, $2.25. 

LA ROCHE ON YELLOW FEVER, considered in 
its Historical, Pathological, Etiological and 
Therapeutical Relations. In two large and hand- 
some octavo volumes of 1468 pp. Cloth, $7.00. 



A CENTURY OF AMERICAN MEDICINE, 1776—1876. By Drs. E. H. Claeke, H. J. 
Biselow, S. D. Geoss, T. G. Thomas, and J. S. Billings. In one 12mo. volume of 370 pages. Cloth, $2.25. 



[Lea Brothers & Co.'s Publications — Systems of Med. 15 

For Sale by Subscription Only, 



A System of Practical Medicine. 

BY AMERICAN AUTHORS. 
Edited by WILLIAM PEPPER, M. D., LL. D., 

PKOVOST AND PROFESSOR OF THE THEORY AND PRACTICE OF MEDICINE AND OF 
CETNICAE MEDICINE IN THE UNIVERSITY OF PENNSYLVANIA, 

Assisted by Louis Starr, M. D., Clinical Professor of the Diseases of Children in the 

Hospital of the University of Pennsylvania. 

In five imperial octavo volumes, containing about 1100 pages each, with illustrations. Price per 

volume, cloth, $5; leather, $6 ; half Russia, raised bands and open back, $7. Volumes 

I, II. and III, containing 3438 pages and 106 illustrations, are now ready. 

Volume IV. will be ready in February, 1886, and Volume V. in June. 

In this great work American medicine will be for the first time represented by its 
worthiest teachers, and presented in the full development of the practical utility which is its 
preeminent characteristic. The most able men — from the East and the West, from the 
North and the South, from all the prominent centres of education, and from all the 
hospitals which afford special opportunities for study and practice — have united in 
generous rivalry to bring together this vast aggregate of specialized experience. 

The distinguished editor has so apportioned the work that each author has had 
assigned to him the subject which he is peculiarly fitted to discuss, and in which his views 
will be accepted as the latest expression of scientific and practical knowledge. The 
practitioner will therefore find these volumes a complete, authoritative and unfailing work 
of reference, to which he may at all times turn with full certainty of finding what he needs 
in its most recent aspect, whether he seeks information on the general principles of medi- 
cine, or minute guidance in the treatment of special disease. So wide is the scope of the 
work that, with the exception of midwifery and matters strictly surgical, it embraces the 
whole domain of medicine, including the departments for which the physician is accustomed 
to rely on special treatises, such as diseases of women and children, of the genito-urinary 
organs, of the skin, of the nerves, hygiene and sanitary science, and medical ophthalmology 
and otology. Moreover, authors have inserted the formulas which they have found most 
efficient in the treatment of the various affections. It may thus be truly regarded as a 
Complete Library of Practical Medicine, and the general practitioner possessing it 
may feel secure that he will require little else in the daily round of professional duties. 

In spite of every effort to condense the vast amount of practical information fur- 
nished, it has been impossible to present it in less than 5 large octavo volumes, containing 
about 5500 beautifully printed pages, and embodying the matter of about 15 ordinary 
octavos. Illustrations are introduced wherever they serve to elucidate the text. 

As material for the work is substantially complete in the hands of the editor, the pro- 
fession may confidently await the appearance of the remaining volumes upon the dates 
above specified. A detailed prospectus of the work will be sent to any address on appli- 
cation to the publishers. 

It is a large undertaking, but quite justifiable in j tained a merited popularity immediately on the 
the case of a progressive nation like the United issue of the first volume, is in no way inferior to 
States. At any rate, if we may judge of future | its predecessors. This "System of Medicine by 
volumes from the first, it will be justified by the American Authors" isamonument to American 
result. We have nothing but praise to bestow j medicine. — Journal, of American Medical Associa- 
upon the work. The articles are the work of I twn, December 5, 1885. 

writers, many of whom are already recognized in I * * In all, from the longest to the shortest, 
this country as authorities on the particular topics j there are evidences of much research and great 
on which they deal, whilst the others show by the painstaking in the preparation of the articles, and 
way they have handled their subjects that "they these several treatises present the most complete 



are fully equal to the task they had undertaken 
* * * A work which we cannot doubt will make 
a lasting reputation for itself. — London Medical 
Times and Gazette, May 9, 1885. 
The third volume of this great work, which at- 



and thorough consideration of the various sub- 
jects that can be found in medical literature. "We 
congratulate the medical reader upon such an 
acquisition to his library.— Atlanta Medical and 
Surgical Journal, December, 1885. 



REYNOLDS, J. RUSSELL, 31. !>., 

Professor of the Principles and Practice of Medicine in University College, London. 

A System of Medicine. With notes and additions by Henrv Hartshorne, 
A. M., M. D., late Professor of Hygiene in the University of Pennsylvania. In three large 
and handsome octavo volumes, containing 3056 double-columned pages, with 317 illustra- 
tions. Price per volume, cloth, $5.00 ; sheep, $6.00; very handsome half Russia, raised bands, 
$6.50. Per set, cloth, $15 ; leather, $18 ; half Russia, $19.50. Sold only by subscription. 



16 Lea Brothers & Co.'s Publications — Clinical Med., etc. 



STILLF, ALFRED, 31. F., LL. F., 

Professor Emeritus of the Theory and Practice of Med. and of Clinical Med. in the Univ. of Penna. 
Cholera: Its Origin, History, Causation, Symptoms, Lesions, Prevention and Treat- 
ment. In one handsome 12mo. volume of 163 pages, with a chart. Cloth, $1.25. Jmt ready. 
The threatened importation of cholera into the country renders peculiarly timely 
this work of an authority upon the subject so eminent as Professor Stilly. The history 
of previous epidemics, their modes of propagation, the vast recent additions to our 
knowledge of the causation, prevention and treatment of the disease, all have been handled 
so skilfully as to present with brevity the information which every practitioner should 
possess in advance of a visitation. 

for a rational system. Altogether, the monograph 

the 



This timely little work is full of the learning 
and good judgment which marks all that comes 
from the pen of its distinguished author. What 
he has to say on treatment is characterized by 
his usual caution and his well-known preference 



is one that will have an excellent influence on 
professional mind.— Medical and Surgical Reporter, 
August 1, 1885. q. 



FLINT, AUSTIN, M. F. 

Clinical Medicine. A Systematic Treatise on the Diagnosis and Treatment of 
Diseases. Designed for Students and Practitioners of Medicine. In one large and hand- 
some octavo volume of 799 pages. Cloth, $4.50 ; leather, $5.50 ; half Russia, $6.00. 

sistently with brevity and clearness, the different 
subjects and their several parts receiving the 
attention which, relatively to their importance, 
medical opinion claims for them, is still more diffi- 
cult. This task, we feel bound to say, has been 
executed with more than partial success by Dr. 
Flint, whose name is already familiar to students 
of advanced medicine in this country as that of 
the author of two works of great merit on special 
subjects, and of numerous papers exhibiting much 
originality and extensive research. — The Dublin 
Journal, Dec. 1879. 



It is here that the skill and learning of the great 
clinician are displayed. He has given us a store- 
house of medical knowledge, excellent for the stu- 
dent, convenient for the practitioner, the result of 
a long life of the most faithful clinical work, col- 
lected by an energy as vigilant and systematic as 
untiring, and weighed by a judgment no less clear 
than his observation is close. — Archives of Medicine, 
Dec. 1879. 

To give an adequate and useful conspectus of the 
extensive field of modern clinical medicine is a task 
of no ordinary difficulty; but to accomplish this con- 



By the Same Author. 

Essays on Conservative Medicine and Kindred Topics. In one very hand- 
some royal 12mo. volume of 210 pages. Cloth, $1.38. 

BBOAFBF2TT, W. FL., M. F., F. It. C. F., 

Physician to and Lecturer on Medicine at St. Mary's Hospital. 
The Pulse. In one 12mo. volume. See Series of Clinical Manuals, page 4. 

SCFCBFIBFB, DM. JOSFFM. 

A Manual of Treatment by Massage and Methodical Muscle Ex- 
ercise. Translated by Walter Mendelson, M. D., of New York. In one handsome 
octavo volume of about 300 pages, with about 125 fine engravings. Preparing, 

FIJSLAYSON, JAMFS, M; F., Editor, 

Physician and Lecturer on Clinical Medicine in the Glasgow Western Infirmary, etc. 
Clinical Diagnosis. A Handbook for Students and Practitioners of Medicine. 
With Chapters by Prof. Gairdner on the Physiognomy of Disease ; Prof. Stephens on 
Diseases of the Female Organs ; Dr. Robertson on Insanity ; Dr. Gemmell on Physical 
Diagnosis ; Dr. Coats on Laryngoscopy and Post-Mortem Examinations, and by the Editor 
on Case-taking, Family History and Symptoms of Disorder in the Various Systems. In 
one handsome 12mo. volume of 546 pages, with 85 illustrations. * Cloth, $2.63. 

FFNWICK, SA3IUFL, M. F., 

Assistant Physician to the London Hospital. 

The Student's Guide to Medical Diagnosis. From the third revised and 
enlarged English edition. In one very handsome royal 12mo. volume of 328 pages, with 
87 illustrations on wood. Cloth, $2.25. 

TAJNJSTFB, TMOMAS MAWKFS, M. F. 

A Manual of Clinical Medicine and Physical Diagnosis. Third American 
from the second London edition. Eevised and enlarged by Tilbury Fox, M. D. 
In one small 12mo. volume of 362 pages, with illustrations. Cloth, $1.50. 

FOIMFBGILL, J. M., M. F., Fdin., M. B. C. F., Lond., 

Physician to the City of London Hospital for Diseases of the Chest. 

The Practitioner's Handbook of Treatment ; Or, The Principles of Thera- 
peutics. New edition. In one octavo volume. Preparing. 

STURGES' INTRODUCTION TO THE STUDY I DAVIS' CLINICAL LECTURES ON VARIOUS 
OF CLINICAL MEDICINE. Being a Guide to IMPORTANT DISEASES. By N. S. Davis, 
the Investigation of Disease. In one handsome M. D. Edited by Frank H. Davis, M. D. Second 
l2mo. volume of 127 pages. Cloth, $1.25. I edition. 12mo. 287 pages. Cloth, $1.75. 



Lea Brothers & Co.'s Publications — Hygiene, Electr., Pract. 17 



BICHABJDSON, B. W. 9 M.A., M.I>., LL. L>., F.B.S., F.S.A. 

Fellow of the Royal College of Physicians, London. 
Preventive Medicine. In one octavo volume of 729 pages. Cloth, $4; leather, 
$5 ; very handsome half Russia, raised hands, $5.50. 
Dr. Richardson has succeeded in producing a the question of disease is comprehensive, masterly 



work which is elevated in conception, comprehen- 
sive in scope, scientific in character, systematic in 
arrangement, and which is written in a clear, con- 
cise and pleasant manner. He evinces the happy 
faculty of extracting the pith of what is known on 
the subject, and of presenting it in a most simple, 
intelligent and practical form. There is perhaps 
no similar work written for the general public 
thatcontains such acomplete, reliable and instruc- 
tive collection of data upon the diseases common 
to the race, their origins, causes, and the measures 
for their prevention. The descriptions of diseases 
are clear, chaste and scholarly ; the discussion of 



and fully abreast with the latest and best knowl- 
edge on the subject, and the preventive measures 
advised are accurate, explicit and reliable. — The 
American Journalof the Medical Sciences, April, 1884. 

This is a book that will surely find a place on the 
table of every progressive physician. To the 
medical profession, whose duty is quite as much to 
prevent as to cure disease, the book will be a boon. 
— Boston Medical and Surgical Journal, Mar. 6, 1884. 

The treatise contains a vast amount of solid, valu- 
able hygienic information. — Medical and Surgical 
Reporter, Feb. 23, 1884. 



BABTHOLOW, BOBEBTS, A. M., M. L>., LL. L)., 

Prof, of Materia Medica and General Therapeutics in the Jefferson Med. Coll. of Phila., etc. 
Medical Electricity. A Practical Treatise on the Applications of Electricity 



to Medicine and Surgery. Second edition, 
pages, with 109 illustrations. Cloth, $2.50. 

The second edition of this work following so 
soon upon the first would in itself appear to be a 
sufficient announcement: nevertheless, the text 



In one very handsome octavo volume of 292 

A most excellent work, addressed by a practi- 
tioner to his fellow-practitioners, and therefore 
thoroughly practical. The work now before us 
has been so considerably revised and condensed, i has the exceptional merit of clearly pointing out 
and so much enlarged by the addition of new mat- I where the benefits to be derived from electricity 
. ter, that we cannot fail to recognize a vast improve- j must come. It contains all and everything that 
ment upon the former work. The author has pre- | the practitioner needs in. order to understand in- 
pared his work for students and practitioners— for ; telligently the nature and laws of the agent he is 
those who have never acquainted themselves with , making use of, and for its proper application in 
the subject, or, having done so, find that after a | practice. In a condensed, practical form, it pre- 
time their knowledge needs refreshing. We think ] sents to the physician all that he would wish to 
he has accomplished this object. The book is not I remember after perusing a whole library on medical 
too voluminous, but is thoroughly practical, sim- ' electricity, including the results of the latest in- 
ple, complete and comprehensible. It is, more- | vestigations. It is the book for the practitioner, 
over, replete with numerous illustrations of instru- i and the necessity for a second edition proves that 
ments, appliances, etc. — Medical Record, November I it has been appreciated by the profession. — Physi- 
16, 1882. | cian and Surgeon, Dec. 1882. 



THE YEAB-BOOK OF TREATMENT FOB 1884. 

A Comprehensive and Critical Review for Practitioners of Medi- 
cine. In one 12mo. volume of 320 pages, bound in limp cloth, with red edges, $1.25. 

This work presents to the practitioner not only a complete classified account of all 
the more important advances made in the treatment of Disease during the year ending 
Sept. 30, 1884, but also a critical estimate of the same by a competent authority. Each 
department of practice has been fully and concisely treated, and into the consideration of 
each subject enter such allusions to recent pathological and clinical work as bear directly 
upon treatment. As the medical literature of all countries has been placed under contri- 
bution, the references given throughout the work, together with the separate indexes oi 
subjects and authors, will serve as a guide for those who desire to investigate any thera- 
peutical topic at greater length. 



In a few moments the busy practitioner can re- 
fresh his mind as to the principal advances in 
treatment for a year past. This kind of work is 
peculiarly useful at the present time, when current 
literature is teeming with innumerable so-called 
advances, of which the practitioner has not time 
to determine the value. Here he has, collected 
from many sources, a resume of the theories and 
facts which are new, either entirely or in part, the 
decision as to their novelty being made by those 
who by wide reading and long experience are 
fully competent to render such a verdict. — Ameri- 



can Journal of the Medical Sciences, April, 1885. 

It is a complete account of the more important 
advances made in the treatment of disease. Ex- 
treme pains have been taken to explain clearly in 
the fewest possible words the views of each 
writer, and the details of each subject. One of 
the principle points about the book is its practical, 
yet concise language. Each editor has well per- 
formed his duty, and we can say with truth that 
it is a volume well worth buying for frequent use. 
— Virginia Medical Monthly, March, 1885. 



TELE YEAB-BOOK OF TBEATMEWT FOB 1885. 

Arranged to correspond with that of 1884, as above. In press. 



HABEBSHON, S. O., M. L>., 

Senior Physician to and late Led. on Principles and Practice of Med. at Guy's Hospital, London. 
On the Diseases of the Abdomen ; Comprising those of the Stomach, and 
other parts of the Alimentary Canal, (Esophagus, Caecum, Intestines and Peritoneum. Second 
American from third enlarged and revised English edition. In one handsome octavo 
volume of 554 pages, with illustrations. Cloth, $3.50. 



TODD'S CLINICAL LECTURES ON CERTAIN I HOLLAND'S MEDICAL NOTES AND REFLEC- 
ACUTE DISEASES. In one octavo volume of TIONS. 1 vol. 8vo., pp. 493. Cloth, $3.50. 
320 pages. Cloth, $2.50. 



18 Lea Brothers & Co.'s Publications — Throat, Lungs, Heart. 



COHEN, J. SOLI8, M. JD. 9 

Lecturer on Laryngoscopy and Diseases of the Throat and Chest in the Jefferson Medical College. 

Diseases of the Throat and Nasal Passages. A Guide to the Diagnosis and 
Treatment- of Affections of the Pharynx, (Esophagus, Trachea, Larynx and Nares. Third 
edition, thoroughly revised and rewritten, with a large number of new illustrations. In 
one very handsome octavo volume. Preparing. 



SEILEM, CAUL, M. !>., 

Lecturer on Laryngoscopy in the University of Pennsylvania. 

A Handbook of Diagnosis and Treatment of Diseases of the Throat, 
Nose and Naso-Pharynx. Second edition. In one handsome royal 12mo. volume 

of 294 pages, with 77 illustrations. Cloth, $1.75. 



It is one of the best of the practical text-books 
on this subject with which we are acquainted. The 
present edition has been increased in size, but its 
eminently practical character has been main- 
tained. Many new illustrations have also been 
introduced, a case-record sheet has been added, 
and there are a valuable bibliography and a good 
index of the whole. For any one who wishes to 
make himself familiar with the practical manage- 
ment of cases of throat and nose disease, the book 
will be found of great value. — New York Medical 
Journal, June 9, 1883. 

The work before us is a concise handbook upon 



the essentials of diagnosis and treatment in dis- 
eases of the throat and nose. The art of laryngos- 
copy, the anatomy of the throat and nose and the 
pathology of the mucous membrane are discussed 
with conciseness and ability. The work is pro- 
fusely illustrated, excels in many essential feat- 
ures, and deserves a place in the office of the 
practitioner who would inform himself as to the 
nature, diagnosis and treatment of a class of dis- 
eases almost inseparable from general medical 
practice. With advanced students the book must 
be very popular on account of its condensed style. 
— Louisville Medical News, June 26, 1883. 



BROWNE, LENNOX, F. B. C. S., Edin., 

Senior Surgeon to the Central London Throat and Ear Hospital, etc. 
The Throat and its Diseases. Second American from the second English edi- 
tion, thoroughly revised. With 100 typical illustrations in colors and 50 wood engravings, 
designed and executed by the Author. In one very handsome imperial octavo volume of 
about 350 pages. Preparing. 

FLINT, AUSTIN, M. D., 

Professor of the Principles and Practice of Medicine in Bellevue Hospital Medical College, N. Y. 

A Mannal of Auscultation and Percussion ; Of the Physical Diagnosis of 
Diseases of the Lungs and Heart, and of Thoracic Aneurism. Fourth edition. In one 
handsome royal 12mo. volume of 278 pages, with 14 illustrations. Cloth, $1.75. Just ready. 

BY THE SAME AUTHOR. 

Physical Exploration of the Lungs by Means of Auscultation and 
Percussion. Three lectures delivered before the Philadelphia County Medical Society, 
1882-83. In one handsome small 12mo. volume of 83 pages. Cloth, $1.00. 

A Practical Treatise on the Physical Exploration of the Chest and 
the Diagnosis of Diseases Affecting the Respiratory Organs. Second and 
revised edition. In one handsome octavo volume of 591 pages. Cloth, $4.50. 

Phthisis: Its Morbid Anatomy, Etiology, Symptomatic Events and 
Complications, Fatality and Prognosis, Treatment and Physical Diag- 
nosis ; I n a series of Clinical Studies. In one handsome octavo volume of 442 pages. 
Cloth, $3.50. — _ 

A Practical Treatise on the Diagnosis, Pathology and Treatment of 
Diseases of the Heart. Second revised and enlarged edition. In one octavo volume 
of 550 pages, with a plate. Cloth, $4. 

GROSS, 8. JD., M.D., LL.D., D.C.L. Oxon., LL.D. Cantab. 

A Practical Treatise on Foreign Bodies in the Air-passages. In one 

octavo volume of 452 pages, with 59 illustrations. Cloth, $2.75. 



FULLER ON DISEASES OF THE LUNGS AND 
AIR-PASSAGES. Their Pathology, Physical Di- 
agnosis, Symptoms and Treatment. From the 
second and revised English edition. In one 
octavo volume of 475 pages. Cloth, $3.50. 

SLADE ON DIPHTHERIA; its Nature and Treat- 
ment, with an account of the History of its Pre- 
valence in various Countries. Second and revised 
edition. In one l2mo. vol., pp. 158. Cloth, $1.25. 

WALSHE ON THE DISEASES OF THE HEART 
AND GREAT VESSELS. Third American edi- 
tion. In 1 vol. 8vo., 416 pp. Cloth, $3.00. 

PAVY'S TREATISE ON THE FUNCTION OF DI- 
GESTION; its Disorders and their Treatment. 
From the second London edition. In one octavo 
volume of 238 pages. Cloth, $2.00. 



CHAMBERS' MANUAL OF DIET AND REGIMEN 
IN HEALTH AND SICKNESS. In one hand- 
some oetavo volume of 302 pp. Cloth, $2.75. 

SMITH ON CONSUMPTION ; its Early and Reme- 
diable Stages. 1 vol. 8vo., pp. 253. Cloth, $2.25. 

LA ROCHE ON PNEUMONIA. 1 vol. 8vo. of 490 
pages. Cloth, $3.00. 

WILLIAMS ON PULMONARY CONSUMPTION; 
its Nature, Varieties and Treatment. With an 
analysis of one thousand cases to exemplify its 
duration. In one 8vo. vol. of 303 pp. Cloth, $2.50. 

jonp:s' CLINICAL OBSERVATIONS on FUNC- 
TIONAL NERVOUS DISORDERS. Second Am- 
erican edition. In one handsome octavo volume 
of 340 pages. Cloth, 83.25. 

BARLOW'S MANUAL OF THE PRACTICE OF 
MEDICINE. With additions by D. F. Condib, 
M. D. 1 vol. 8vo., pp. 603. Cloth, $2.50. 



Lea Brothers & Co.'s Publications — Nerv. and M ent. Dis., etc. 19 
ROSS, JAMES, M.I)., F.R. C.F., LL. D., 

Senior Assistant Physician to the Manchester Royal Infirmary. 

A Text-Book on Diseases of the Nervous System. In one handsome 
octavo volume of 725 pages, with 184 illustrations. Cloth, $4.50 ; leather, $5.50. Just 
ready. 

The author has intended this handbook for the use of students, and for that large class 
of practitioners who are so full)'' occupied in practice that but little time is left them 
for reading lengthy treatises. Bearing in mind the wants of these classes, he has given 
outlines of the anatomy and physiology of the nervous system, and has devoted the 
greater part of the space at command to a thoroughly practical exposition of the various 
nervous diseases, including differential diagnosis and treatment. 

MITCHELL, S. WEIR, M. JO., 

Physician to Orthopaedic Hospital and the Infirmary for Diseases of the Nervous System, Phila., etc. 

Lectures on Diseases of the Nervous System; Especially in Women. 
Second edition. In one 12mo. volume of 288 pages. Cloth, $1.75. 

We feel sure that the new edition of Dr. Mitch- 
ell's admirable lectures will be received on this 
side of the Atlantic with more than ordinary at- 



tention. His subject, the nervous disorders of 



women, is one that interests every practitioner, 
and his views on treatment are gradually receiving 
general acceptance.— London Medical Times and 
Gazette, July 4, 1885. 



HAMILTON, ALLAN McLAJSE, M. D., 

Attending Physician at the Hospital for Epileptics and Paralytics, BlackwelVs Island, N. Y. 
Nervous Diseases ; Their Description and Treatment. Second edition, thoroughly 
revised and rewritten. In one octavo volume of 598 pages, with 72 illustrations. Cloth, $4. 
When the first edition of this good book appeared | characterized this book as the best of its kind in 



we gave it our emphatic endorsement, and the 
present edition enhances our appreciation of the 
book and its author as a safe guide to students of 
clinical neurology. One of the best and most 
critical of English neurological journals, Brain, has 



any language, which is a handsome endorsement 
from an exalted source. The improvements in the 
new edition, and the additions to it, will justify its 
purchase even by those who possess the old.— 
Alienist and Neurologist, April, 1882. 



TUKE, DAJSIEL HACK, M. D., 

Joint Author of The Manual of Psychological Medicine, etc. 

Illustrations of the Influence of the Mind upon the Body in Health 
and Disease. Designed to elucidate the Action of the Imagination. New edition. 
Thoroughly revised and rewritten. In one handsome octavo volume of 467 pages, with 
two colored plates. Cloth, $3.00. 



It is impossible to peruse these interesting chap- 
ters without being convinced of the author's per- 
fect sincerity, impartiality, and thorough mental 
grasp. Dr. Tuke has exhibited the requisite 
amount of scientific address on all occasions, and 
the more intricate the phenomena the more firmly 
has he adhered to a physiological and rational 



method of interpretation. Guided by an enlight- 
ened deduction, the author has reclaimed for 
science a most interesting domain in psychology, 
previously abandoned to charlatans and empirics. 
This book, well conceived and well written, must 
commend itself to every thoughtful understand- 
ing. — New York Medical Journal, September 6, 1884. 



CLOUSTOJST, THOMAS S., M. D., F. R. C. F., L. It. C. S., 

Lecturer on Mental Diseases in the University of Edinburgh. 

Clinical Lectures on Mental Diseases. With an Appendix, containing an 
Abstract of the Statutes of the United States and of the Several States and Territories re- 
lating to the Custody of the Insane. By Chahi/es F. Folsom, M. D., Assistant Professor 
of Mental Diseases, Medical Department of Harvard University. In one handsome 
octavo volume of 541 pages, illustrated with eight lithographic plates, four of which 
are beautifully colored. Cloth, $4. 

The practitioner as well as the student will ac- the general practitioner in guiding him to a diag- 
ceptthe plain, practical teaching of the author as a nosis and indicating the treatment, especially in 
forward step in the literature of insanity. It is many obscure and doubtful cases of mental dis- 
refreshing to find a physician of Dr. Clouston's ease. To the American reader Dr. Folsom's ^In- 
experience and high reputation giving the bed- pendix adds greatly to the value of the work, and 
side notes upon which his experience has been will make it a desirable addition to every library, 
founded and his mature judgment established. —American Psychological Journal, July, 1884. 
Such clinical observations cannot but be useful to 



)r. Folsom's Abstract may also be obtained separately in one octavo volume of 
108 pages. Cloth, $1.50. 

SAVAGE, GEORGE H., M. JD., 

Lecturer on Mental Diseases at Guy's Hospital, London. 
Insanity and Allied Neuroses, Practical and Clinical. In one 12mo. vol- 
ume of 551 pages, with 18 typical illustrations. Cloth, $2.00. See Series of Clinical 
Manuals, page 4. 

FLATFAIR, W. S., M. !>., F. R. C. P., 

The Systematic Treatment of Nerve Prostration and Hysteria. In 

one handsome small 12mo. volume of 97 pages. Cloth, $1.00. 



Blandford on Insanity and its Treatment: Lectures on the Treatment 

Medieal and Legal, of Insane Patients. In one very handsome octavo volume. 



20 



Lea Brothers & Co.'s Publications — Surgery. 



ASHHTJBST, JOHN, Jr., 31. D., 

Professor of Clinical, Surgery, Unw. of Penna., Surgeon to the Episcopal Hospital, Philadelphia. 

The Principles and Practice of Surgery. New (fourth) edition, enlarged 
and revised. In one large and handsome octavo volume of 1114 pages, with 597 illustra- 
tions. Cloth, $6 ; leather, $7 ; half Russia, $7.50. Just ready. 

rience and a scholar of rare attainments, and as 



This thoroughly practical work has now ad- 
vanced to the fourth edition. A large amount of 
valuable matter lias been added, necessitating an 
increase of fifty pages. It has fairly earned for 
itself the reputation of a standard work on sur- 
gery, and is abundantly able to stand on its own 
merits. The author is a surgeon of large expe- 



such he has infused a personality into his work 
which cannot fail to be appreciated by the student 
in quest of broad principles, or the surgeon who 
wishes to be guided by a master.— Medical Record, 
Nov. 7, 1885. 



gboss, s. n., 3i. n., ll. jd., n. c. l. oxon., ll. d. 

Cantab., 

Emeritus Professor of Surgery in the Jefferson Medical College of Philadelphia. 
A System of Surgery: Pathological, Diagnostic, Therapeutic and Operative. 
Sixth edition, thoroughly revised and greatly improved. In two large and beautifully- 
printed imperial octavo volumes containing 2382 pages, illustrated by 1623 engravings. 
Strongly bound in leather, raised bands, $15 ; half Russia, raised bands, $16. 



Dr. Gross' System of Surgery has long been the 
standard work on that subject for students and 
practitioners. — London Lancet, May 10, 1884. 

The work as a whole needs no commendation. 
Many years ago it earned for itself the enviable 
reputation of the leading American work on sur- 
gery, and it is still capable of maintaining that 
standard. A considerable amount of new material 
has been introduced, and altogether the distin- 
guished author has reason to be satisfied that he 
has placed the work fully abreast of the state of 
our knowledge.— Med. Record, Nov. 18, 1882. 



His System of Surgery, which, since its first edi- 
tion in 1859, has been a standard work in this 
country as well as in America, in "the whole 
domain of surgery," tells how earnest and labori- 
ous and wise a surgeon he was how thoroughly 
he appreciated the work done by men in other 
countries, and how much he contributed to pro- 
mote the science and practice of surgery in his 
own. There has been no man to whom America 
is so much indebted in this respect as the Nestor 
of surgery. — British Medical Journal, May 10, 1884. 



STIMSOW, LEWIS A., B. A., 31. L>., 

Prof, of Pathol. Anat. at the Univ. of the City of New York, Surgeon and Curator to Bellevue Hosp. 

A Manual of Operative Surgery. New (second) edition. In one very hand- 
some royal 12mo. volume of 503 pages, with 342 illustrations. Cloth, $2.50. Just ready. 
Of the first edition, a large proportion was exhausted in Great Britain, and the ap- 
proval of the two English-speaking races has seemed to the author to justify an adherence 
to the original plan in preparing the new edition. Besides revising the work he has 
included all advances due to the introduction of the antiseptic system of treating wounds, 
and, in short, has incorporated careful descriptions of all useful operations which have 
been invented during the past few years. 

GOULD, A. BEABCE, 31. S., 31. B., F. B. C. S., 

Assistant Surgeon to Middlesex Hospital. 

Elements of Surgical Diagnosis. In one pocket-size 12mo. volume of 589 

pages. Cloth, $2.00. Just ready. See Students' Series of Manuals, page 4. 



GIBJSTET, V. P., 31. JD., 

Surgeon to the Orthopaedic Hospital, New York, etc. 
Orthopssdic Surgery. For the use of Practitioners and Students. In one hand- 
some octavo volume, profusely illustrated. Preparing. 



BOBEBTS, JOTTW B., A. 31., 31. D., 

Lecturer on Anatomy and on Operative Surgery at the PhiloAelphia School of Anatomy. 

The Principles and Practice of Surgery. For the use of Students and 
Practitioners of Medicine and Surgery. In one very handsome octavo volume of about 500 
pages, with many illustrations. Preparing. 

BELLA31Y, EDWABD, F. B. C. $,, 

Surgeon and Lecturer on Surgery at Charing Cross Hospital, London. 
Operative Surgery. Shortly. See Students' Series of Manuals, page 4. 



SARGENT ON BANDAGING and OTHER OPERA- 
TIONS OF MINOR SURGERY. New edition, 
with a Chapter on military surgery. One I'imo. 
volume of 383 pages, with 187 cuts. Cloth, $1.75. 
MILLER'S PRINCIPLES OF SURGERY. Fourth 
American from the third Edinburgh edition. In 
one 8vo. vol. of 638 pages, with 340 illustrations. 
Cloth, $3.75. 
MILLER'S PRACTICE OF SURGERY. Fourth 
E ' and revised American from the last Edinburgh 
" edition. In one large 8vo. vol. of 682 pages, with 
364 illustrations. Cloth, $3.75. 



PIRRIE'S PRINCIPLES AND PRACTICE OF 
SURGERY. Edited by John Neill, M. D. In 
one 8vo. vol. of 784 pp. with 316 illus. Cloth, $3.75. 

COOPER'S LECTURES ON THE PRINCIPLES 
AND PRACTICE OF SURGERY. Inone 8vo. vol. 
of 767 pages. Cloth, $2.00. 

SKEY'S OPERATIVE SURGERY. In one vol. 8vo. 

of 661 pages, with 81 woodcuts. Cloth, $3.25. 
GIBSON'S INSTITUTES AND PRACTICE OF 

SURGERY. Eighth edition. In two octavo vols. 

of 965 pages, with 34 plates. Leather $6.50. 



Lea Brothers & Co.'s Publications — Surgery. -21 

EJRICHSEJT, JOHW E. 9 F. JR. S., F. JR. C. S., 

Professor of Surgery in University College, London, etc. 

The Science and Art of Surgery ; Being a Treatise on Surgical Injuries, Dis- 
eases and Operations. From the eighth and enlarged English edition. In two large and 
beautiful octavo volumes of 2316 pages, illustrated with 984 engravings on wood. 
Cloth, $9; leather, raised bands, $11 ; half Russia, raised bands, $12. 



In noticing the eighth edition of this well- 
known work, it would appear superfluous to say 
more than that it has, like its predecessors, been 
brought fully up to the times, and is in conse- 
quence one of the best treatises upon surgery that 
has ever been penned by one man. We nave al- 
ways regarded "The Science and Art of Surgery" 



years and maintaining during that period a re- 
putation as a leading work on surgery, there is not 
much to be said in the way of comment or criti- 
cism. That it still holds it's own goes without say- 
ing. The author infuses into it his large experi- 
ence and ripe judgment. Wedded to no school, 
committed to no theory, biassed by no hobby, he 



as one of the best surgical text-books in the imparts an honest personality in his observati >ns, 
English language, and this eighth edition only | and his teachings are the rulings of an impartial 



confirms our previous opinion. We take great 
pleasure in cordially commending it to our read- 
ers.— The Medical News, April 11, 1885. 
After being before the profession for thirty 



judge. Such men are always safe guides, and their 
works stand the tests of* time and experience. 
Such an author is Erichsen, and sucn a work is his 
Surgery.— Medical Record, Feb. 21, 1885. 



BJRTAJST, THOMAS, F. JR. C. 8., 

Surgeon and Lecturer on Surgery at Guy's Hospital, London. 
The Practice of Surgery. Fourth American from the fourth and revised Eng- 
lish edition. In one large and very handsome imperial octavo volume of 1040 pages, with 
727 illustrations. Cloth, $6.50; leather, $7.50; half Russia, $8.00. 

The treatise takes in the whole field of surgery, I This most magnificent work upon surgery has 
that of the eye, the ear, the female organs, ortho- j reached a fourth edition in this country, showing 
ptedi s, venereal diseases, and military surgery, the high appreciation in which it is held by the 
as well as more common and general topics. All | American profession. It comes fresh from the 
of these are treated with clearness and with j pen of the author. That it is the very best work 
sufficient fulness to suit all practical purposes. ! on surgery for medical students * we think 
The illustrations are numerous and well printed. ' there can be no doubt. The author seems to have 
We do not doubt that this new edition will con- i understood just what a student needs, and has 
tinue to maintain the popularity of this standard ; prepared the work accordingly. — Cincinnati Medical 
work.— Medical and Surgical Reporter, Feb. 14, '85. j flews, January, 18S5. 



By the same Author. 
Diseases of the Breast. In one 12mo. volume. Preparing. See Series of Clinical 
Manuals, page 4. 

JBTJTJLIJF, HFJS T JRT T., F. JR. C. S., 

Assistant Surgeon to St. Bartholomew's Hospital, London. 
Diseases of the Tongue. In one 12mo. volume of 456 pages, with 8 colored 
plates and 3 woodcuts. Cloth, $3.50. Just ready. See Series of Clinical Manuals, page 4. 
This book, the latest issue of the "Clinical been written by one whose opportunities have 
Manuals for Practitioners and Students of peculiarly fitted him for the task, since he teaches 
Medicine," is a model of its kind. It is not only from a clinical but from a pathological 
specially welcome, all the more so, since the text standpoint. We heartily commend the book to 
is really illustrated by a sufficient, number of our readers. — The Medical News, October 17, 1885. 
admirably executed colored plates. The work has , 



ESMAJRCH, Dr. FBIEJDJRICH, 

Professor of Surgery at the University of Kiel, etc. 

Early Aid in Injuries and Accidents. Five Ambulance Lectures. Trans- 
lated by H. K. H. Princess Christian. In one handsome small 12mo. volume of 109 
pages, with 24 illustrations. Cloth, 75 cents. 

The course of instruction is divided into five the methods of affording first treatment in cases 
sections or lectures. The first, or introductory of frost-bite, of drowning, of suffocation, of loss of 
lecture, gives a brief account of the structure and j consciousness and of poisoning are described; 
organization of the human body, illustrated by ! and the fifth lecture teaches how injured persons 
clear, suitable diagrams. The second teaches how I may be most safely and easily transported to their 
to give judicious help in ordinary injuries — contu- j homes, to a medical man, or to a hospital. The 
sions, wounds, haemorrhage and poisoned wounds, illustrations in the book are clear and good. — Medi- 
The third treats of first aid in cases of fracture cat Times and Gazette, Nov. 4, 1882. 
and of dislocations, in sprains and in burns. Next, | 



TJREVES, FJREDEJRICK, F. JR. C. S., 

Assistant Surgeon to and Lecturer on Surgery at the London Hospital. 

Intestinal Obstruction. In one pocket-size 12mo. volume of 522 pages, with 60 
illustrations. Limp cloth, blue edges, $2.00. Just ready. See /Series of Clinical Manuals, 
page 4. 

A standard work on a subject that has not been | justice to the author in a few paragraphs. Intes- 
so comprehensively treated by any contemporary \ final Obstruction is a work that will prove of 
English writer. Its completeness renders a full j equal value to the practitioner, the student, the 
review difficult, since every chapter deserves mi- j pathologist, the physician and the operating sur- 
nute attention, and it is impossible to do thorough j geon.— British Medical Journal, Jan. 31, 1885. 



BALL, CHAJRLES B., 31. Ch., JDub., F. JR. C. S. E., 

Surgeon and Teacher at Sir P. Dun's Hospital, Dublin. 

Diseases of the Rectum and Anus. In one 12mo. volume of 550 pages. 
Preparing. See Series of Clinical Manuals, page 4. 



22 Lea Brothers & Co.'s Publications — Surgery 

HOLMES, TIMOTHY, M. A., 

Surgeon and Lecturer on Surgery at St. George's Hospital, London. 

A System of Surgery ; Theoretical and Practical. IN TREATISES BY 
VARIOUS AUTHORS. American edition, thoroughly revised and re-edited 
by John H. Packard, M. D., Surgeon to the Episcopal and St. Joseph's Hospitals, 
Philadelphia, assisted by a corps of thirty-three of the most eminent American surgeons. 
In three large and very handsome imperial octavo volumes containing 3137 double- 
columned pages, with 979 illustrations on wood and 13 lithographic plates, beautifully 
colored. Price per volume, cloth, $6.00 : leather, $7.00 ; half Russia, $7.50. Per set, cloth, 
$18.00 ; leather, $21.00 ; half Russia, $22.50. Sold only by subscription. 

This great work, issued some years since in England, has won such universal confi- 
dence wherever the language is spoken that its republication here, in a form more 
thoroughly adapted to the wants of the American practitioner, has seemed to be a duty 
owing to the profession. To accomplish this, each article has been placed in the hands ot 
a gentleman specially competent to treat its subject, and no labor has been spared to bring 
each one up to the foremost level of the times, and to adapt it thoroughly to the practice 
of the country. In certain cases this has rendered necessary the substitution of an entirely 
new essay for the original, as in the case of the articles on Skin Diseases, on Diseases of 
the Absorbent System, and on Anaesthetics, in the use of which American practice differs 
from that of England. The same careful and conscientious revision has been pursued 
throughout, leading to an increase of nearly one-fourth in matter, while the series of 
illustrations has been nearly trebled, and the whole is presented as a complete exponent 
of British and American Surgery, adapted to the daily needs of the working practitioner. 

In order to bring it within the reach of every member of the profession, the five vol- 
umes of the original have been compressed into three by employing a double-columned 
royal octavo page, and in this improved form it is offered at less than one-half the price of the 
original. It is printed and bound to match in every detail with Reynolds' System of Medi- 
cine. The work will be sold by subscription only, and in due time every member of the 
profession will be called upon and offered an opportunity to subscribe. 

The authors of the original English edition are the library of any medical man. It is more wieldly 
men of the front rank in England, and Dr. Packard and more useful than the English edition, and with 
has been fortunate in securing as his American its companion work — "Reynolds' System of Medi- 
coadjutors such men as Bartholow, Hyde, Hunt, cine" — will well represent the present state of our 
Conner, Stimson, Morton, Hodgen, Jewell and science. One who is familiar with those two works 
their colleagues. As a whole, the work will be will be fairly well furnished head-wise and hand- 
solid and substantial, and a valuable addition to wise. — The Medical News. Jan. 7, 18S2. 



STIMSOJS T , LEWIS A., B. A., M. L>., 

Professor of Pathological Anatomv at the University of the City of Xetc York, Surgeon and Curator 
to Bellevue' Hospital", Surgeon to the Presbyterian Hospital, Sew York, etc. 

A Practical Treatise on Fractures. In one very handsome octavo volume of 

59S pages, with 360 beautiful illustrations. Cloth, $4.75 ; leather, $5.75. 

The author has given to the medical profession the surgeon in full practice. — N. O. Medical and 

in this treatise on fractures what is likely to be- Surgical Journal, March, 1SS3. 

come a standard work on the subject. It is certainly The author give s in clear language all that the 
not surpassed by any work written in the English, pract i ca i SU rgeon need know of the science of 
or, for that matter, any other language. The au- fractures, their etiologv, svmptoms, processes of 
thor tells us in a short, concise and comprehensive union and treatment^according to the latest de- 
manner, all that is known about his subject. There velopments. On the basis of mechanical analysis 
is nothing scanty or superficial about it as in most the autnor aC curatelv and clearlv explains the 
other treatises; on the contrary everything is thor- clinical features of fractures, and bv the same 
ough. The chapters on repair of fractures and their met hod arrives at the proper diagnosis snd rational 
treatment show him not only to be a profound stu- Creat ment. A thorough explanation of the patho- 
dent, but likewise a practical surgeon and patholo- i 02 ieal anatomv and a careful description of the 
gist. His mode of treatment of the different fract- Ya >i ou? methods of procedure make the book full 
uresis eminently sound and practical. We consider of va i ue for e _ erv praC titioner.— Centralblatt fur 
this work one of the best on fractures : and it will Chirurgie Mav 19 1883 
be welcomed not onlv as a text-book, but also by *-*■** 



JDBFITT, BOBFBT, M. B. C. S., etc. 

The Principles and Practice of Modern Surgery. From the eighth 
London edition. In one Svo. volume of 687 pages, with 432 illus. Cloth, $4 ; leather, $5. 



MABSH, HOWABD, F. B. C. S., 

Senior Assistant Surgeon to and Lecturer on Anatomy at St. Bartholomew's Hospital, London. 
Diseases of the Joints. In one 12mo. volume. Preparing. See Series of Clinical 
Manuals, page 4. 

PICK, T. BICKFBUSG, F. B. C. S., 

Surgeon to and Lecturer on Surgery at St. George's Hospital, London. 

Fractures and Dislocations. In one 12mo. volume. Shortly. See Series of 
Clinical Manuals, page 4. 



Lea Brothers & Co.'s Publications — Frac, Disloc, Ophthal. 2cT 



HAMILTON, FRANK H., 31. D., LL. D., 

Surgeon to Bellevue Hospital, New York. 

A Practical Treatise on Fractures and Dislocations. Seventh edition, 
thoroughly revised and much improved. In one very handsome octavo volume of 998 

Cloth, $5.50: leather, §6.50; very handsome half Russia, 



pages, with 379 illustrations, 
open back, $7.00. 

Hamilton's great experience and wide acquaint- 
ance with the fiterature of the subject have enabled 
him to complete the labors of Malgaigne and to 
place the reader in possession of the advances 
made during thirty years. The editions have fol- 
lowed each other rapidly, and they introduce us 
to the methods of practice, often so wise, of his 
American colleagues. More practical than Mal- 
gaigne's work, it will serve as a valuable guide to 
the practitioner in the numerous and embarrass- 
ing cases which come under his observation.— 
Archives Generates de MMecine, Paris, Nov. 1884. 

This work, which, since its first appearance 
twenty-five years ago,, has gone through many 
editions, and been much enlarged, may now be 
fairly regarded as the authoritative book of refer- 
ence on the subjects of lractures and dislocations. 
Each successive edition has been rendered of 
greater value through the addition of more re- 



cent work, and especially of the recorded re- 
searches and improvements made by the author 
himself and his countrymen. — British Medical 
Journal, May 9, 1885. 

With its first appearance in 1859, this work took 
rank among the classics in medical literature, 
and has ever since been quoted by surgeons the 
world over as an authority upon the topics of 
which it treats. The surgeon, if one can be found 
who does not already know the work, will find it 
scientific, forcible and scholarly in text, exhaustive 
in detail, and ever marked by a spirit of wise con- 
servatism. — Louisville Medical Neus, Jan. 10, 1885. 

For a quarter of a century the author has been 
elaborating and perfecting his work, so that it 
now stands as the best of its kind in any lan- 
guage. As a text-book and as a book of reference 
and guidance for practitioners it is simply invalu- 
able. — Sew Orleans Med. and Surg. Journal, Nov. 1884. 



JTJLER, SEJSRT E., F. R. C. S., 

Senior Ass't Surgeon, Royal Westminster Ophthalmic Hosp. ; late Clinical Ass't, Moorfields, London. 

A Handbook of Ophthalmic Science and Practice. In one handsome 
octavo volume of 460 pages, with 125 woodcuts, 27 colored plates, selections from the 
Test-types of Jaeger and Snellen, and Holmgrens Color-blindness Test. Cloth, $4.50 ; 
leather, $5.50. 

This work is distinguished by the great num- 
ber of colored plates which appear in it for illus- 
trating various pathological conditions. They are 
very oeautiful in appearance, and have been 
executed with great care as to accuracy. An ex- 
amination of the work shows it to be one of high 
standing, one that will be regarded as an authority 
among ophthalmologists. The treatment recom- 
mended is such as the author has learned from 
actual experience to be the best. — Cincinnati Medi- 
cal yens, Dec. 1884. 



it *»CC.O, i-/GU. LOOT. j UCU15, p 1 £\IJ L 1 1. H J 

It presents to the student concise descriptions | Lancet, Jan. 1885 



and typical illustrations of all important eye 
affections, placed in juxtaposition, so as to be 

§ rasped at a glance. Beyond a doubt it is the 
est illustrated handbook of ophthalmic science 
which has ever appeared. Then, what is still 
better, these illustrations are nearly all original. 
We have examined this entire work with great 
care, and it represents the commonly accepted 
views of advanced ophthalmologists. We can most 
heartily commend this book to all medical stu- 
dents, practitioners and specialists. — Detroit 



WELLS, J. SOELBERG, F. R. C. S., 

Professor of Ophthalmology in King^s College Hospital, London, ete. 

A Treatise on Diseases of the Eye. Fourth American from the third London 
edition. Thoroughly revised, with copious additions, by Charles S. Bull, M. D., Surgeon 
and Pathologist to the New York Eye and Eur Infirmary. In one large octavo volume of 
822 pages, with 257 illustrations on wood, six colored plates, and selections from the Test- 
types of Jaeger and Snellen. Cloth, $5.00 ; leather, $6.00 ; halt Russia, $6.50. 



The present edition appears in less than three 
years since the publication of the last American 
edition, and yet, from the numerous recent inves- 
tigations that have been made in this branch of 
medicine, many changes and additions have been 
required to meet the present scope of knowledge 
upon this subject. A critical examination at once 



shows the fidelity and thoroughness with which 
the editor has accomplished his part of the work. 
The illustrations throughout are good. This edi- 
tion can be recommended to all as a complete 
treatise on diseases of the eye, than which proba- 
bly none better exists. — Medical Record, Aug. 18. '83, 



JSETTLESJBLIF, EDWARD, F. R. C. S., 

Ophthalmic Surg, and Led. on Ophth. Surg, at St. Thomas' Hospital, London. 

The Student's Guide to Diseases of the Eye. Second edition. With a chap- 
ter on the Detection of Color-Blindness, by William Thomson, aI. D., Ophthalmologist 
to the Jefferson Medical College. In one royal 12mo. volume of 416 pages, with 138 
illustrations. Cloth, $2.00. 

This admirable guide bids fair to become the \ and well chosen. This book, within the short com- 
favorite text-book on ophthalmic surgery with stu- i pass of about 400 pages, contains a lucid exposition 
dents and general practitioners. It bears through- of the modern aspect of ophthalmic science. — 
out the imprint of sound judgment combined with j Medical Record, June 23, 1883. 
vast experience. The illustrations are numerous | 

BROWNE, EDGAR A., 

Surgeon to the Liverpool Eye and Ear Infirmary and to the Dispensary for Skiti Diseases. 
How to Use the Ophthalmoscope. Being Elementary Instructions in Oph- 
thalmoscopy, arranged for the use of Students. In one small royal 12mo. volume of 116 
pages, with 35 illustrations. Cloth, $1.00. 



LAWSON ON INJURIES TO THE EYE, ORBIT 
AND EYELIDS: Their Immediate and Remote 
Effects. 8 vo., 404 pp., 92 illus. Cloth, $3.50. 

LAURENCE AND MOON'S HANDY BOOK OF 
OPHTHALMIC SURGERY, for the use of Prac- 



titioners. Second edition. In one octavo vol- 
ume of 227 pages, with 65 illust. Cloth, $2.75. 
CARTER'S PRACTICAL TREATISE ON DISEAS- 
ES OF THE EYE. Edited by John Green, M. D. 
In one handsome octavo volume. 



24 Lea Brothers & Co.'s Publications — Otol., Urin. Dis., Dent. 



BURNETT, CHARLES H., A. M., 31. D., 

Professor of Otologji in the Philadelphia Polyclinic; President of the American Otological Society. 

The Ear, Its Anatomy, Physiology and Diseases. A Practical Treatise 
for the use of Medical Students and Practitioners. New (second) edition. In one handsome 
octavo volume of 580 pages, with 107 illustrations. Cloth, $4.00 ; leather, $5.00. 

"We note with pleasure the appearance of a second carried out, and much new matter added. Dr. 

edition of this valuable work. When it first came Burnett's work must be regarded as a very valua- 

out it was accepted by the profession as one of ble contribution to aural surgery, not only on 

the standard works on modern aural surgery in account of its comprehensiveness, but because it 

the English language; and in his second edition contains the results of the careful personal observa- 

Dr. Burnett has fully maintained his reputation, tion and experience of this eminent aural surgeon, 

for the book is replete with valuable information — London Lancet, Feb. 21, 1885. 
and suggestions. The revision has been carefully 



FOLITZER, ADAM, 

Imperial- Royal Prof, of Aural Th.erap. in the Univ. of Vienna. 

A Text-Book of the Ear and its Diseases. Translated, at the Author's re 
quest, by James Patterson Casseees, M. D., M. R. C. S. In one handsome octavo vol 
ume of 800 pages, with 257 original illustrations. Cloth, $5.50. 

The work itself we do not hesitate to pronounce 
the best upon the subject of aural diseases which 
has ever appeared, systematic without being too 
diffuse on obsolete subjects, and eminently prac- 
tical in every sense. The anatomical descriptions 



of each separate division of the ear are admirable, 
and profusely illustrated by woodcuts. They are 
followed immediately by the physiology of the 



section, and this again by the pathological physi- 
ology, an arrangement which serves to keep up the 
interest of the student by showing the direct ap- 
plication of what has preceded to the study of dis- 
ease. The whole work can be recommended as a 
reliable guide to the student, and an efficient aid 
to the practitioner in his treatment. — Boston Med- 
ical and Surgical Journal, June 7, 1883. 



ROBERTS, WILLIAM, 31. !>., 

Lecturer on Medicine in the Manchester School of Medicine, etc. 

A Practical Treatise on Urinary and Renal Diseases, including Uri- 
nary Deposits. Fourth American from the fourth London edition. In one hand- 
some octavo volume of 609 pages, with 81 illustrations. Cloth, $3.50. Just ready. 

Dr. Roberts does this work in a manner which 
bears testimony to his accurate methods of study 
and rare common- sense. The work as now re- 



vised is more fully than ever adapted to the needs 
of the practitioner. — American Practitioner, Sep- 
tember, 1885. 

The work is practical in its character, and is 
regarded as an authority in the diseases which it 



treats. There is certainly no work that more 
fully sets forth the progress that has been made 
than this one of Dr. Roberts, and that more fully 
meets the wants of the physician in explaining 
the best methods of treatment. We have no 
hesitation in recommending it to our subscribers. 
— Cincinnati Medical News, June, 1885. 



GROSS, s. n., M. n., LL. I>., I). C. L., etc. 

A Practical Treatise on the Diseases, Injuries and Malformations 
of the Urinary Bladder, the Prostate Gland and the Urethra. Third 
edition, thoroughly revised by Samuel W. Gross, M. D., Professor of the Principles of 
Surgery and of Clinical Surgery in the Jefferson Medical College, Philadelphia. In one 
octavo volume of 574 pages, with 170 illustrations. Cloth, $4.50. 

MORRIS, HENRY, 31. B., F. R. C. S., 

Surgeon to and Lecturer on Surgery at Middlesex Hospital, London. 

Surgical Diseases of the Kidney. In one 12mo. volume. Shortly. See 
Series of Clinical Manuals, page 4. 



LUCAS, CLE3IENT, M. B., B. S., F. R. C. S., 

Senior Assistant Surgeon to Guy's Hospital, London. 
Diseases of the Urethra. In one 12mo. volume. Preparing. See Series 
of Clinical Manuals, page 4. 

TH03IFSON, SIR HENRY, 

Surgeon and Professor of Clinical Surgery to University College Hospital, London. 

Lectures on Diseases of the Urinary Organs. Second American from the 
third English edition. In one 8vo. volume of 203 pp., with 25 illustrations. Cloth, $2.25. 

By the Same Author. 
On the Pathology and Treatment of Stricture of the Urethra and 
Urinary Pistulse. From the third English edition. In one octavo volume of 359 
pages, with 47 cuts and 3 plates. Cloth, $3.50. 

COLEMAN, A., L. R. C. F., F. R. C. S., Exam. L. 2>. S., 

Senior Dent. Surg, and Lect. on Dent. Surg, at St. Bartholomew's Hosp. and the Dent. Hosp., London. 

A Manual of Dental Surgery and Pathology. Thoroughly revised and 
adapted to the use of American Students, by Thomas C. Stellwagen, M. A., M. D., 
D. D. S., Prof, of Physiology at the Philadelphia Dental College. In one handsome octavo 
volume of 412 pages, with 331 illustrations. Cloth, $3.25. 

BASHAM ON RENAL DISEASES : A Clinical I one 12mo. vol. of 304 pages, with 21 illustrations. 
Guide to their Diagnosis and Treatment. In | Cloth, $2.00. 



Lea Brothers & Co.'s Publications — Venereal, Impotence. 



25 



TAYLOR, It. W., 

A. 31., M. J>., 

Surgeon to Charity Hospital, New York, Prof, of 
Venereal and Skin Diseases in the University oj 
Vermont, Pres. of the Am. Dermatol ogical Ass'n. 



BUMSTEAJD, F. J., mid 

M. D., LL. D., 

Late Professor of Venereal Diseases 
at the College of Physicians and 
Surgeons, New York, etc. 

The Pathology and Treatment of Venereal Diseases. Including the 
results of recent investigations upon the subject. Fifth edition, revised and largely re- 
written, by Dr. Taylor. In one large and handsome octavo volume of 898 pages with 
139 illustrations, and thirteen chroino-litliographic figures. Cloth, $4.75 ; leather, $5.75 ; 
very handsome half Eussia, $6.25. 



It is a splendid record of honest labor, wide 
research, just comparison, careful scrutiny and 
original experience, which will always be held as 
a high credit to American medical literature. This 
is not only the best work in the English language 
upon the subjects of which it treats, but also one 
which has no equa. in other tongues for its clear, 
comprehensive and practical handling of its 
themes. — American Journal of the Medical Sciences, 
Jan, 1884. 

It is certainly the best single treatise on vene- 
real in our own, and probably the best in any lan- 
guage. — Boston Medical and Surgical Journal, April 
3, 1884. 



The character of this standard work is so well 
known that it would be superfluous here to pass in 

i review its general or special points of excellence. 
The verdict of the profession has been passed; it 
has been accepted as the most thorough and com- 

; plete exposition of the pathology and treatment of 
venereal diseases in the language. Admirable as a 
model of clear description, an exponent of sound 
pathological doctrine, and a guide for rational and 
successful treatment, it is an ornament to the medi- 

i cal literature of this country. The additions made 

j to the present edition are eminently judicious, 
from the standpoint of practical utility. — Journal oj 

, Cutaneous and Venereal Diseases, Jan. 1884. 



COBNIL, V., 

Professor to the Faculty of Medicine of Paris, and Physician to the Lourcine Hospital. 

Syphilis, its Morbid Anatomy, Diagnosis and Treatment. Specially 
revised by the Author, and translated with notes and additions by J. Henry C. Simes, 
M. D., Demonstrator of Pathological Histology in the University of Pennsylvania, and 
J. William White, M. D., Lecturer on Venereal Diseases and Demonstrator of Surgery 
in the University of Pennsylvania. In one handsome octavo volume of 461 pages, with 
84 very beautiful illustrations. Cloth, $3.75. 
The anatomical and histological characters ofjhe | the whole volume is the clinical experience of the 

author or the wide acquaintance of the translators 
with medical literature more evident. The anat- 
omy, the histology, the pathology and the clinical 
features of syphilis are represented in this work in 
their best, most practical and most instructive 
form, and no one will rise from its perusal without 
the feeling that his grasp of the wide and impor- 
tant subject on which it treats is a stronger and 
surer one. — The London Practitioner, Jan. 1882. 



hard and soft sore are admirably described. The 
multiform cutaneous manifestations of the disease 
are dealt with histologically in a masterly way, as 
we should indeed expect them to be, and the 
accompanying illustrations are executed carefully 
and well. "The various nervous lesions which are 
the recognized outcome of the syphilitic dyscrasia 
are treated with care and consideration. Syphilitic 
epilepsy, paralysis, cerebral syphilis and locomotor 
ataxia are subjects full of interest ; and nowhere in 



HUTCHINSON, JONATHAN, F. JR. S., F. M. C. S., 

Consulting Surge-on to the London Hospital. 
Syphilis. In one 12mo. volume. Preparing. See Series of Clinical Manuals, page 4. 



GBOSS, SA3IUEL W., A. M., M. D., 

Professor of the Principles of Surgery and of Clinical Surgery in the Jefferson Medical College. 

A Practical Treatise on Impotence, Sterility, and Allied Disorders 
of the Male Sexual Organs. Second edition, thoroughly revised. In one very hand- 
some octavo volume of 168 pages, with 16 illustrations. Cloth, $1.50. 

The author of this monograph is a man of posi- This work will derive value from the high stand- 
tive convictions and vigorous style. This is justi- | ing of its author, aside from the fact of its passing 



fied by his experience and by his study, which has 
gone hand in hand with his experience. In regard 
to the various organic and functional disorders of 
the male generative apparatus, he has had ex- 
ceptional opportunities for observation, and his 
book shows that he has not neglected to compare 
his own views with those of other authors. The 
result is a work which can be safely recommended 
to both physicians and surgeons as a guide in the 
treatment of the disturbances it refers to. It is 
the best treatise on the subject with which we are 
acquainted.— The Medical News, Sept. 1, 1883. 



so rapidly into its second edition. This is, indeed, 
a book that every physician will be glad to place 
in his library, to be read with profit to himself, 
and with incalculable benefit to his patient. Be- 
sides the subjects embraced in the title, which are 
treated of in their various forms and degrees, 
spermatorrhoea and prostatorrhcea are also fully 
considered. The work is thoroughly practical in 
character, and will be especially useful to the 
general practitioner. — Medical Record, Aug. 18, 
1883. 



CULLERIFR, A., & BU3ISTFAD, F. jr., 3I.JD., LL.JD., 



Surgeon to the Hdpital du Midi. 



Late Professor of Venereal Diseases in the College of Physicians 
and Surgeons, New York. 



An Atlas of Venereal Diseases. Translated and edited by Freeman J. Bum- 
stead, M. D. In one imperial 4to. volume of 328 pages, double-columns, with 26 plates, 
containing about 150 figures, beautifully colored, many of them the size of life. Strongly 
bound in cloth, $17.00. A specimen of the plates and text sent by mail, on receipt of 25 cts. 

HILL ON SYPHILIS AND LOCAL CONTAGIOUS FORMS OF LOCAL DISEASE AFFECTING 
DISORDERS. In one 8vo vol. of 479 p. Cloth, $3.25. PRINCIPALLY THE ORGANS OF GENERA- 
LEE'S LECTURES ON SYPHILIS AND SOME j TION. In one 8vo. vol. of 246 pages. Cloth, $2.25. 



26 



Lea Brothers & Co.'s Publications — Diseases of Skin. 



HYDE, J. KEVINS, A. M., M. JD., 

Professor of Dermatology and Venereal Diseases in Rush Medical College, Chicago. 

A Practical Treatise on Diseases of the Skin. For the use of Students and 
Practitioners. In one handsome octavo volume of 570 pages, with 66 beautiful and elab- 
orate illustrations. Cloth, $4.25 ; leather, $5.25. 

The author has given the student and practi- 
tioner a work admirably adapted to the wants of 
each. We can heartily commend the book as a 
valuable addition to our literature and a reliable 
guide to students and practitioners in their studies 
and practice. — Am. Journ. of Med. ScL, July, 1883. 



Especially to be praised are the practical sug- 
gestions as to what may be called the common- 
sense treatment of eczema. It is quite impossible 
to exaggerate the judiciousness with which the 
formulae for the external treatment of eczema are 
selected, and what is of equal importance, the full 
and clear instructions for their use. — London Medi- 
cal Times and Gazette, July 28, 1883. 

The work of Dr. Hyde will be awarded a high 
position. The student of medicine will find it 
peculiarly adapted to his wants. Notwithstanding 
the extent of the subject to which it is devoted, 
yet it is limited to a single and not very large vol- 
ume, without omitting a proper discussion of the 
topics. The conciseness of the volume, and the 
setting forth of only what can be held as facts will 
also make it acceptable to general practitioners. 
— Cincinnati Medical News, Feb. 1883. 

The aim of the author has been to present to his 
^readers a work not only expounding the most 
modern conceptions of his subject, but presenting 
what is of standard value. He has more especially 
devoted its pages to the treatment of disease, and 
by his detailed descriptions of therapeutic meas- 
ures has adapted them to the needs of the physi- 



cian in active practice. In dealing with these 
questions the author leaves nothing to the pre- 
sumed knowledge of the reader, but enters thor- 
oughly into the most minute description, so that 
one is not only told what should be done under 
given conditions but how to do it as well. It is 
therefore in the best sense "a practical treatise." 
That it is comprehensive, a glance at the index 
will show. — Maryland Medical Journal, July 7, 1883, 
Professor Hyde has long been known as one of 
the most intelligent and enthusiastic representa- 
tives of dermatology in the west. His numerous 
contributions to the literature of this specialty 
have gained for him a favorable recognition as a 
careful, conscientious and original observer. The 
remarkable advances made in our knowledge of 
diseases of the skin, especially from the stand- 
point of pathological histology and improved 
methods of treatment, necessitate a revision of 
the older text-books at short intervals in order to 
bring them up to the standard demanded by the 
march of science. This last contribution of Dr. 
Hyde is an effort in this direction. He has at- 
tempted, as he informs us, the task of presenting 
in a condensed form the results of the latest ob- 
servation and experience. A careful examinatiod 
of the work convinces us that he has accomplishen 
his task with painstaking fidelity and with a cred- 
itable result. — Journal of Cutaneous and Venereal 
Diseases, June, 1883. 



J^OX, T., M.D., F.B.C.P., and FOX, T.C.,B.A., M.R.C.S., 



Physician to the Department for Skin Diseases, 
University College Hospital, London. 



Physician for Diseases of the Skin to the 
Westminster Hospital, London. 



An Epitome of Skin Diseases. With Formulae. For Students and Prac- 
titioners. Third edition, revised and enlarged. In one very handsome 12mo. volume 
of 238 pages. Cloth, $1.25. 



The third edition of this convenient handbook 
calls for notice owing to the revision and expansion 
which it has undergone. The arrangement of skin 
-diseases in alphabetical order, which is the method 
of classification adopted in this work, becomes a 
positive advantage to the student. The book is 



manual to lie upon the table for instant reference. 
Its alphabetical arrangement is suited to this use, 
for all one has to know is the name of the disease, 
and here are its description and the appropriate 
treatment at hand and ready for instant applica- 
tion. The present edition has been very carefully 



- l 
one which we can strongly recommend, not only revised and a number of new diseases are de" 

to students but also to practitioners who require a i scribed, while most of the recent additions to 

compendious summary of the present state of I dermal therapeutics find mention, and the formu- 

dermatology.— British Medical Journal, July 2, 1883. lary at the end of the book has been considerably 

We cordially recommend Fox's Epitome to those augmented.— The Medical News, December, 1883. 

whose time is limited and who wish a handy | 

MOBBIS, MAICOIM^FbTcTsZ 

Joint Lecturer on Dermatology at St. Mary's Hospital Medical School, London. 
Skin Diseases; Including their Definitions, Symptoms, Diagnosis, Prognosis, Mor- 
bid Anatomy and Treatment. A Manual for Students and Practitioners. In one 12mo. 
volume of 316 pages, with illustrations. Cloth, $1.75. 



To physicians who would like to know something 
about skin diseases, so that when a patient pre- 
sents himself for relief they can make a correct 
diagnosis and prescribe a rational treatment, we 
unhesitatingly recommend this little book of Dr. 
Morris. The affections of the skin are described 
in a terse, lucid manner, and their several charac- 
teristics so plainly set forth that diagnosis will be 
easy. The treatment in each case is such as the 
experience of the mosteminent dermatologists ad- 
vises.— Cincinnati Medical News, April, 1880. 

This is emphatically a learner's book; for we I 



for clearness of expression and methodical ar- 
rangement is better adapted to promote a rational 
conception of dermatology— a branch confessedly 
difficult and perplexing to the beginner. — St. Louis 
Courier of Medicine, April, 1880. 

The writer has certainly given in a small compass 
a large amount of well-compiled information, and 
his little book compares favorably with any other 
which has emanated from England, while in many 
points he has emancipated himself from the stub- 
bornly adhered to errors of others of his country- 
men. There is certainly excellent material in the 



can safely say, that in the whole range of medical book which will well repay perusal.— Boston Med. 
literature there is no book of a like scope which I and Surg. Journ., March, 1880. 

WILSON, EBASMUS, F. B. S. ~~ 

The Student's Book of Cutaneous Medicine and Diseases of the Skin. 

In one handsome small octavo volume of 535 pages. Cloth, $3.50. 

HILLIEB, TJBLOMAS, 31. JD., 

Physician to the Skin Department of University College, London. 

Handbook of Skin Diseases; for Students and Practitioners. Second Ameri- 
can edition. In one 12mo, volume of 353 pages, with plates. Qloth, $2.25. 



Lea Brothers & Co.'s Publications — Dis. ol Women, 



AN AMERICAN SYSTEM OF GYNAECOLOGY. 

A System of Gynaecology, in Treatises by Various Authors. Edited 
by Matthew D. Mann, M. D., Professor of Obstetrics and Gynecology in the Uni- 
versity of Buffalo, N. Y. In two handsome octavo volumes, richly illustrated. In active 
preparation. 

LIST OF CONTRIBUTORS. 



WILLIAM H. BAKER, M. D., 
FORDYCE BARKER, M. D., 
ROBERT BATTEY, M. D., 
SAMUEL C. BUSEY, M. D., 
HENRY F. CAMPBELL, M. D., 
HENRY C. COE, M. D., 
E. C. DUDLEY, M. D , 
GEORGE J. ENGELMANN, M. I 
HENRY F. GARRIGUES, M. D., 
WILLIAM GOODELL, M. D., 
EGBERT H. GRANDIN, M. D., 
SAMUEL W. GROSS, M. D., 
JAMES B. HUNTER, M. D., 
A. REEVES JACKSON, M. D., 



EDWARD W. JENKS, M. D., 
WILLIAM T. LUSK, M. D., 
MATTHEW D. MANN, M. D., 
ROBERT B. MAURY, M. D., 
PAUL F. MUNDE, M. D., 
C. D. PALMER, M. D., 
WILLIAM M. POLK, M. D., 
THADDEUS A. REAMY, M. D., 
A. D. ROCKWELL, M. D., 
ALEX. J. C. SKENE, M. D., 
R. STANSBURY SUTTON, A. M., 
T. GAILLARD THOMAS, M. D., 
ELY VAN DE WARKER, M. D., 
W. GILL WYLIE, M. D. 



M. D. 



THOMAS, T. GAILLARJD, 31. D., 

Professor of Diseases of Women in the College of Physicians and Surgeons, N. Y. 

A Practical Treatise on the Diseases of Women. Fifth edition, thoroughly 
revised and rewritten. In one large and handsome octavo volume of 810 pages, with 266 
illustrations. Cloth, $5.00 ; leather, $6.00 ; very handsome half Russia, raised bands, $6.50. 

vious one. As a book of reference for the busy 
practitioner it is unequalled.— Boston Medical and 
Surgical Journal, April 7, 1880. 

It has been enlarged and carefully revised. It is 
a condensed encyclopaedia of gynaecological medi- 
cine. The style of arrangement, the masterly 
manner in which each subject is treated, and the 
honest convictions derived from probably the 



The words which follow " fifth edition" are in 
this case no mere formal announcement. The 
alterations and additions which have been made are 
both numerous and important. The attraction 
and the permanent character of this book lie in 
the clearness and truth of the clinical descriptions 
of diseases; the fertility of the author in thera- 
peutic resources and the fulness with which the 



details of treatment are described; the definite ( largest clinical experience in that specialty of any 



character of the teaching; and last, but not least, 
the evident candor which pervades it. We would 
also particularize the fulness with which the his- 
tory of the subject is gone into, which makes the 
book additionally interesting and gives it value as 
a work of reference. — London Medical Times and 
Gazette, July 30, 1881. 

The determination of the author to keep his 
book foremost in the rank of works on gynaecology 
is most gratifying. Recognizing the fact that this 
can only be accomplished by frequent and thor- 
ough revision, he has spared no pains to make the 
present edition more desirable even than the pre- 



in this country, all serve to commend it in the 
highest terms to the practitioner. — Nashville Jour* 
of Med. and Surg., Jan. 1881. 

That the previous editions of the treatise of Dr. 
Thomas were thought worthy of translation into 
German, French, Italian and Spanish, is enough 
to give it the stamp of genuine merit. ( At home it 
has made its way into the library of every obstet- 
rician and gynaecologist as a safe guide to practice. 
No small number of additions have been made to 
the present edition to make it correspond to re- 
cent improvements in treatment. — Pacific Medical 
and Surgical Journal, Jan. 1881. 



EDIS, ARTHUR TV., M. JD., Lond., F.R. C.F., M.R. C.S. 9 

Assist. Obstetric Physician to Middlesex Hospital, late Physician to British Lying-in Hospital. 
Thp Diseases of Women. Including their Pathology, Causation, Symptoms, 
Diagnosis and Treatment. A Manual for Students and Practitioners. In one handsome 
octavo volume of 576 pages, with 148 illustrations. Cloth, $3.00 ; leather, $4.00. 

It is a pleasure to read a book so thoroughly i The greatest pains have been taken with the 
good as this one. The special qualities which are sections relating to treatment. A liberal selection 
conspicuous are thoroughness in covering the j of remedies is given for each morbid condition, 
whole ground, clearness of description and con- j the strength, mode of application and other details 
ciseness of statement. Another marked feature of I being fully explained. The descriptions of gynee- 



the book is the attention paid to the details of 
many minor surgical operations and procedures, 
as, for instance, the use of tents, application of 
leeches, and use of hot water injections. These 
are among the more common methods of treat- 
ment, and yet very little is said about thern in 
many of the text-books. The book is one to be 
warmly recommended especially to students and 
general practitioners, who need a concise but com- 
plete resume of the whole subject. Specialists, too, 
will find many useful hints in its pages,— Boston 
Med, and Surg. Journ., March 2, 1882, 



cological manipulations and operations are full, 
clear and practical. Much care has also been be- 
stowed on the parts of the book which deal with 
diagnosis — we note especially the pages dealing 
with the differentiation, one from another, of the 
different kinds of abdominal tumors. The prac- 
titioner will therefore find in this book the kind 
of knowledge he most needs in his daily work, and 
he will be pleased with the clearness and fulness 
of the information there given.— The Practitioner t 
Feb. lSS'g. 



BARNES, ROBERT, M. D., F. R. C. F., 

Obstetric Physician to St. Thomas' 1 Hospital, London, etc. 

A Clinical Exposition of the Medical and Surgical Diseases of Women. 

In one handsome octavo volume, with numerous illustrations. New edition. Preparing. 

WEST, CHARLES, M. JD. 

Lectures on the Diseases of "Women. Third American from the third Lon- 
don edition. In one octavo volume of 543 pages. Cloth, $3.75 ; leather, $4.75. 



28 



Lea Brothers & Co.'s Publications — Dis. of'Womeu, Midwfy. 



EMMET, THOMAS ADDIS, M. D., LL. I)., 

Surgeon to the H'o»m«i'« Hospital, New York, etc. 

The Principles and Practice of Gynaecology ; For the use of Students and 
Practitioners of Medicine. New (third) edition, thoroughly revised. In one large and very 
handsome octavo volume of 880 pages, with 150 illustrations. Cloth, $5; leather, $6; 
very handsome half Russia, raised bands, $6.50. Just ready. 



We are in doubt, whether to congratulate the 
author more than the profession upon the appear- 
ance of the third edition of this well-known work. 
Embodying, as it does, the life-long experience of 
one who has conspicuously distinguished himself 
as a bold and successful operator, and who has 
devoted so much attention to the specialty, we 
feel sure the profession will not fail to appreciate 
the privilege thus otfered them of perusing the 
views and practice of the author. His earnestness 
of purpose and conscientiousness are manifest. 
He gives not only his individual experience but 
endeavors to represent the actual state of gynae- 
cological science and art. — British Medical Jour- 
nal, May 16, 1885. 

No jot or tittle of the high praise bestowed upon 



once a credit to its author and to American med- 
ical literature. We repeat that it is a book to be 
studied, and one that is indispensable to every 
practitioner giving any attention to gynaecology. — 
American Journal of the Medical Sciences, April, 1885. 
The time has passed when Emmet's Gynaecology 
was to be regarded as a book for a single country 
or for a single generation. It has always been his 
aim to popularize gynaecology, to bring it within 
easy reach of the general practitioner. The orig- 
inality of the ideas, aside from the perfect con- 
fidence which we feel in the author's statements, 
compels our admiration and respect. We may 
well take an honest pride in Dr. Emmet's work 
and feel that his book can hold its own against the 
criticism of two continents. It represents all that 



the first edition is abated. It is still a book of is most earnest and most thoughtful in American 



marked personality, one based upon large clinical 
experience, containing large and valuable ad- 
ditions to our knowledge, evidently written not 
only with honesty of purpose, but with a conscien- 
tious sense of responsibility, and a book that is at 



jyneecology. Emmet's work will continue to 
reflect the individuality, the sterling integrity and 
the kindly heart of itshonored author long after 
smaller books have been forgotten. — American 
Journal of Obstetrics, May, 1885. 



DVNCAJSF, J. MATTHEWS, M.I)., LL. D., F. JR. S. E., etc. 

Clinical Lectures on the Diseases of Women ; Delivered in Saint Bar- 
tholomew's Hospital. In one handsome octavo volume of 175 pages. Cloth, $1.50. 

They are in every way worthy of their author ; | rule, adequately handled in the textrbooks; others 
indeed, we look upon them as among the most! of them, while bearing upon topics that are usually 
valuable of his contributions. They are all upon I treated of at length in such works, yet hear such a 
matters of great interest to the general practitioner, j stamp of individuality that they deserve to be 
Some of them deal with subjects that are not, as a \ widely read. — N. Y. Medical Journal, March, 1880. 

MAT, CHARLES H., M. D. 

Late House Surgeon to Mount Sinai Hospital, New Yerk. 
A Manual of the Diseases of Women. Being a concise and systematic expo- 
sition of the theory and practice of gynaecology. In one 12mo. volume of 342 pages. 
Cloth, $1.75. Just ready. 



Medical students will find this work adapted to 
their wants. Also practitioners of medicine will 
find it exceedingly convenient to consult for the 
purpose of refreshing their minds upon the lead- 
ing points of a gynaecological subject. By syste- 
matic condensation, the omission of disputed ques- 



tions, and the presentation onlv of accepted views, 
it constitutes a very satisfactory exposition of the 
leading principles of gynaecology as they are un- 
derstood at the present time. — Cincinnati Medical 
News, Nov. 1885. 



HODGE, HUGHL., M. D., 

Emeritus Professor of Obstetrics, etc., in the University of Pennsylvania. 
On Diseases Peculiar to Women; Including Displacements of the Uterus. 
Second edition, revised and enlarged. In one beautifully printed octavo volume of 519 
pages, with original illustrations. Cloth, $4.50. 

By the Same Author. 

The Principles and Practice of Obstetrics. Illustrated with large litho- 
graphic plates containing 159 figures from original photographs, and with numerous wood- 
cuts. In one large quarto volume of 542 double-columned pages. iStrongly bound in 
cloth, $14.00. Specimens of the plates and letter-press will be forwarded to any address, 
free by mail, on receipt of six cents in postage stamps. 

HAMSBOTHAM, FRANCIS H., 31. D. 

The Principles and Practice of Obstetric Medicine and Surgery; 

In reference" to the Process of Parturition. A new and enlarged edition, thoroughly revised 
by the Author. With additions by W. V. Keating, M. D., Professor of Obstetrics, etc., 
in the Jefferson Medical College of Philadelphia. In one large and handsome imperial 
octavo volume of 640 pages, with 64 full-page plates and 43 woodcuts in the text, contain- 
ing in all nearly 200 beautiful figures. Strongly bound in leather, with raised bands, $7. 



WLNCEEL, F. 

A Complete Treatise on the Pathology and Treatment of Childbed, 

For Students and Practitioners. Translated, with the consent of the Author, from the 
second German edition, by J. K. Chadwick, M. D. Octavo 484 pages. Cloth, $4.00. 



ASHWELL'S PRACTICAL TREATISE ON THE 
DISEASES PECULIAR TO WOMEN. Third 
American from the third and revised London 
edition. In one 8vo. vol., pp. 520. Cloth. §3.50. 

CHURCHILL ON THE PUERPERAL FEVER 



AND OTHER DISEASES PECULIAR TO WO- 
M EN. In one 8vo. vol. of 464 pages. Cloth, $2.50. 
MEIGS ON THE NATURE, SIGNS AND TREAT- 
MENT OF CHILDBED FEVER. In one 8vo. 
volume of 346 pages. Cloth, $2.00. 



Lea Brothers & Co.'s Publications — Midwifery. 29 

BARJNES, ROBERT, 31. JD., and FANCOURT, M. JD., 

Phys. to the General Lying-in Hosp., Lond. Obstetric Phys. to St. Thomas' LTosp., Lond. 

A System of Obstetric Medicine and Surgery, Theoretical and Clin- 
ical. For the Student and the Practitioner. The Section on Embryology contributed by 
Prof. Milnes Marshall. In one handsome octavo volume of 872 pages, with 231 illus- 
trations. Cloth, §o ; leather, $6. Just ready. 

tioner. The great excellence of this "System of 



We find great pleasure in commending so ex- 
cellent and thorough a book to the profession. — 
Obstetric Gazette, October, 18*5. 

The profession generally have long been anxious 



Obstetrics," as it appears to us, consists in the full 
adoption of the utilitarian principles, and the 
perfectly systematic character of the teachings, 



that he should commit his teachings to a syste- ' making it easy to learn, and retain what is learned, 
matic work covering all the subjects usually treated [ Every page imparts some item of instruction 
in a text-book on obstetrics. The present work i which makes each practitioner wish he had known 
satisfies this demand. His son's assistance has | this yesterday, and to feel that he may need that 
been of great help in making this one-volume I to morrow. It is scarcely a venture of prediction 
work the most generally useful one now in print, I that this book, when its contents become known, 
both as a text-book for the student or lecturer, I will be generally adopted by practitioners. — Str- 
and as a favorite reference-book for the practi- | ginia Medical Monthly, December, 1885. 

JPLAYFAIR, W. S., M. JD., F. R. C. JP., 

Professor of Obstetric Medicine in King's College, London, etc. 

A Treatise on the Science and Practice of Midwifery. New (fourth) 
American, from the fifth English edition. Edited, with additions, by Robert P. Har- 
ris, M. D. In one handsome octavo volume of 654 pages, with 3 plates and 201 engrav- 
ings Cloth, $4 ; leather, $5 ; half Russia, $5.50. Just ready. 

This still remains a favorite in America, not ' for students have very much to boast of in this 
only because the author is recognized as a safe respect. — Medical Record. 

guide and eminently progressive man, but also as ] In the short time that this excellent and highly 
sparing no effort to make each successive edition esteemed work has been before the profession it 
a faithful mirror of the latest and best practice, j has reached a fourth edition in this country and a 
A work so frequently noticed as the present ' fifth one in England. This fact alone speaks in 
requires no further review. We believe that this ' high praise of it, and it seems to us that scarcely 
edition is simply the forerunner of many others, j more need be said of it in the way of endorsement 
and that the demand will keep pace with the j of its value. As a text book for'students and for 
supply.— American Journal of Obstetrics, Nov. 1885. ( the uses of the general practitioner there is no 

Since its first publication, only eight years ago, i work on obstetrics superior to the work of Dr. 
it has rapidly become the favorite text-book, to Playfair. Its teachings are practical, written in 
the practical exclusion of all others. A large plain language, and afford a correct understanding 
measure of its popularity is due to the clear and of the art of midwifery. No one can be disap- 
easy style in which it is written. Few text-books ! pointed in it. — Cincinnati Medical News, June, 1885. 



BARKER, FORDYCE, A. 31., 31. JD., XX. JD. Fdin., 

Clinical Professor of Midwifery and the Diseases of Women in the Bellevue Hospital Medical College, 
New York, Honorary Fellow of the Obstetrical Societies of London and Edinburgh, etc., etc. 

Obstetrical and Clinical Essays. In one handsome 12mo. volume of about 
300 pages. Preparing. 

KING, A. F. A., 31. JD., 

Professor of Obstetrics and Diseases of Women in the Medical Department of the Columbian Univer- 
sity, Washington, D. C, and in the University of Vermont, etc. 

A Manual of Obstetrics. Second edition. In one very handsome 12mo. volume 
of 331 pages, with .59 illustrations. Cloth, §2.00. 

It must be acknowledged that this is just what I densed style of composition, the writer has pre- 
it pretends to be — a sound guide, a portable epit- | sented a great deal of what it is well that every 
ome. a work in which only indispensable matter | obstetrician should know and be ready to practice 
has been presented, leaving out all padding and j or prescribe. The fact that the demand for the 
chaff, and one in which the student will find pure volume has been such as to exhaust the first 
wheat or condensed nutriment. — New Orleans Med- edition in a little over a year and a half speaks 
ical and Surgical Journal, May, 1884-. well for its popularity. — American Journal of the 

In a series of short paragraphs and by a con- Medical Sciences, April, 1884. 

BARNES, FANCOURT, M. JD., 

Obstetric Physician to St. Thomas' 1 Hospital, London. 

A Manual of Midwifery for Midwives and Medical Students. In one 

royal 12mo. volume of 197 pages, with 50 illustrations. Cloth, §1.25. 



JPARVIN, THEOFHILVS, 31. JD., XX. JD., 

Professor of Obstetrics and the Diseases of Women and Children in the Jefferson Medical College. 
A Treatise on Midwifery. In one very handsome octavo volume of about 550 
pages, with numerous illustrations. In press. 

BARRY, JOHN $., 31. JD., 

Obstetrician to the Philadelphia Hospital, Vice-President of the Obstet. Society of Philadelphia. 
Extra - Uterine Pregnancy: Its Clinical History, Diagnosis, Prognosis and 
Treatment. In one handsome octavo volume of 272 pages. Cloth, $2.50. 



TANNER, TM03IAS MAWKES, M. JD. 

On the Signs and Diseases of Pregnancy. First American from the second 
English edition. Octavo, 490 pages, with 4 colored plates and 16 woodcuts. Cloth, $4.25. 



30 Lea Brothers & Co.'s Publications — Midwly., Dis. Childn. 



LEISJEEMAN, WILLIAM, 31. D., 

Regius Professor of Midwifery in the University of Glasgow, etc. 

A System of Midwifery, Including the Diseases of Pregnancy and the 
Puerperal State. Third American edition, revised by the Author, with additions by 
John S. Parry, M. D., Obstetrician to the Philadelphia Hospital, etc. In one large and 
very handsome octavo volume of 740 pages, with 205 illustrations. Cloth, $4.50 ; leather, 
$5.50 ; very handsome half Russia, raised bands, $6.00. 



The author is broad in his teachings, and dis- 
cusses briefly the comparative anatomy of the pel- 
vis and the mobility of the pelvic articulations. 
The second chapter is devoted especially to 
the siiidy of the pelvis, while in the third the 
female organs of generation are introduced. 



this, the last edition of this well-known work, every 
recent advancement in this field has been brought 
forward. — Physician and Surgeon, Jan. 1880. 

To the American student the work before us 
must prove admirably adapted. Complete in all its 
parts, essentially modern id its teachings, and with 



The structure and development of the ovum are i demonstrations noted for clearness and precision! 
admirably described. Then follow chapters upon it will gain in favor and be recognized as a work 
the various subjects embraced in the study of mid- | of standard merit. The work cannot fail to be 
wifery. The descriptions throughout the work are popular and is cordially recommended. — N. O. 
plain and pleasing. It is sufficient to state that in | Med. and Surg. Journ., March, 1880. 



LANJDIS, HENRY G., A. M., M. D., 

Professor of Obstetrics and the Diseases of Women in Starling Medical College, Columbus, O. 

The Management of Labor, and of the Lying-in Period. In one 

handsome 12mo. volume of 334 pages, with 28 illustrations. Cloth, $1.75. Just ready. 



It is a practical, sound clinical work, making the 
impression of having been written at the bed-side 
as a guide for the bed-side. The author's individ- 
uality is apparent throughout, embodying his own 
personal experience. The language is fluent, 
clear and forcible; free from all redundancy or 



needless repetitions. We heartily commend it to 
all for whom it is intended, and will add, that it 
will well repay perusal by those who are beyond 
the years of the /'young practitioner." — Cincin- 
nati Lancet and Clinic, Nov. 21, 1885. 



S3HTJBC, J. LEWIS, 31. JD., 

Clinical Professor of Diseases of Children in the Bellevue Hospital Medical College, N. 7. 

A Treatise on the Diseases of Infancy and Childhood. New (sixth) 
edition, thoroughly revised and rewritten. In one handsome octavo volume of over 800 
pages, with illustrations. Cloth, $4.50 ; leather, $5.00 ; half Eussia, $6.00. Just ready. 

From the Preface. 

The constant endeavor of the author, as successive editions of this treatise have been 
called for, has been to make it more useful to the medical student and to the physician in 
his daily practice. He has avoided discussion of theories, except as they influence practice, 
while he has devoted more space- to the therapeutics of the various diseases. He has 
been stimulated to this by constant intercourse with physicians, so as to be able to 
appreciate their wants, and by letters of inquiry sent by physicians, which, for the most 
part, relate to matters of treatment. 

KEATING, JOHN 31., M. JD., 

Lecturer on the Diseases of Children at the University of Pennsylvania, etc. 

The Mother's Guide in the Management and Feeding of Infants. In 

one handsome 12mo. volume of 118 pages. Cloth, $1.00. 



"Works like this one will aid the physician im- 
mensely, for it saves the time he is constantly giv- 
ing his patients in instructing them on the sub- 
jects here dwelt upon so thoroughly and prac- 
tically. Dr. Keating has written a practical book, 
has carefully avoided unnecessary repetition, and 
successfully instructed the mother in such details 
of the treatment of her child as devolve upon her. 
He has studiously omitted giving prescriptions, 
and instructs the mother when to call upon the 
doctor, as his duties are totally distinct from hers. 
— American Journal of Obstetrics, October, 1881. 



Dr. Keating has kept clear of the common fault 
of works of this sort, viz., mixing the duties of 
the mother with those proper to the doctor. There 
is the ring of common sense in the remarks about 
the employment of a wet-nurse, about the proper 
food for a nursing mother, about the tonic effects 
of a bath, about the pei^mbulator versus the nurses, 
arms, and on many other subjects concerning 
which the critic might say, "surely this is obvi~ 
ous," but which experience teaches us are exactly 
the thingsneededtobe insisted upon, with the rich 
as well as the poor. — London Lancet, January 28, 1882, 



OWEN, EJD3IUNJD, 31. B., F. M. C. S., 

Surgeon to the Children's Hospital, Great Ormond St., London. 

Surgical Diseases of Children. In one 12mo. volume. Shortly. See Series of 

Clinical Manuals, page 4, 

WEST, CJBTAMLES, 31. JD., 

Physician to the Hospital for Sick Children, London, etc. 

Lectures on the Diseases of Infancy and Childhood. Fifth American 
from 6th English edition. In one octavo volume of 686 pages. Cloth, $4.50 ; leather, $5.50. 

By the Same Author. 

On Some Disorders of the Nervous System in Childhood. In one small 
12mo. volume of 127 pages. Cloth, $1.00. 

CONDIE'S PRACTICAL TREATISE ON THE I vised and augmented. In one octavo volume oi 
DISEASES OF CHILDREN. Sixth edition, re- | 779 pages. Cloth, $5.25 ; leather, $6.25. 



Lea Brothers & Co.'s Publications — Med. Juris., Miscel. 31 

TIDY, CHARLES MEYMOTT, M. B., E. C. S., 

Professor of Chemistry and of Forensic Medicine and Public Health at the London Hospital, etc. 

Legal Medicine. Volume II. Legitimacy and Paternity, Pregnancy, Abor- 
tion, Rape, Indecent Exposure, Sodomy, Bestiality, Live Birth, Infanticide, Asphyxia, 
Drowning, Hanging, Strangulation, Suffocation. Making a very handsome imperial oc- 
tavo volume of 529 pages. Cloth, $6.00; leather, $7.00. 

Volume I. Containing 664 imperial octavo pages, with two beautiful colored 
plates. Cloth, $6.00 ; leather, $7.00. 

The satisfaction expressed with the first portion tables of eases appended to each division of the 
of this work is in no wise lessened by a perusal of subject, must have cost the author a prodigious 
the second volume. We find it characterized by amount of labor and research, but they constitute 
the same fulness of detail and clearness of ex- one of the most valuable features of the book, 
pression which we had occasion so highly to com- especially for reference in medico-legal trials. — 
mend in our former notice, and which render it so American Journal of the Medical Sciences, April, 1884. 
valuable to the medical jurist. The copious ! 



TAYLOR, ALFRED S., M. D., 

Lecturer on Medical Jurisprudence and Chemistry in Guy's Hospital, London. 

A Manual of Medical Jurisprudence. Eighth American from the tenth Lon- 
don edition, thoroughly revised and rewritten. Edited by John J. Eeese, M. D., Professor 
of Medical Jurisprudence and Toxicology in the University of Pennsylvania. In one 
large octavo volume of 937 pages, with 70 illustrations. Cloth, $5.00 ; leather, $6.00 ; half 
Kussia, raised bands, $6.50. 

The American editions of this standard manual only have to seek for laudatory terms. — American 
have for a long time laid claim to the attention of Journal of the Medical Sciences, Jan. 1881. 
the profession in this country; and the eighth ; This celebrated work has been the standard au- 
comes before us as embodying the latest thoughts thority in its department for thirty-seven years, 
and emendations of Dr. Taylor upon the subject , both in England and America, in both the profes- 
to which he devoted his life with an assiduity and s i ns which it concerns, and it is improbable that 
success which made him Jacile princeps among it will be superseded in many years. The work is 
English writers on medical jurisprudence. Both , simply indispensable to every physician, and nearly 
the author and the book have made a mark too so to every liberalty-educated lawyer, and we 
deep to be affected by criticism, whether it be heartily commend the present edition to both pro- 
oensure or praise. In this case, however, we should fessions — Albany Law Journal, March 26, 1881. 



By the Same Author. 

The Principles and Practice of Medical Jurisprudence. Third edition. 
In two handsome octavo volumes, containing 1416 pages, with 188 illustrations. Cloth, $10 ; 
leather, $12. Just ready. 

For years Dr. Taylor was the highest authority j matters connected with the subject," shouid be 
in England upon the subject to which he gave brought up to the present day and continued in 
especial attention. His experience was vast, his j its authoritative position. To accomplish this re- 
judgment excellent, and his skill beyond cavil. It ! suit Dr. Stevenson has subjected it to most careful 
is therefore well that the work of one who, as Dr. | editing, bringing it well up to the times. — Amert- 
Stevenson says, had an "enormous grasp of all | can Journal of the Medical Sciences, Jan. 1884. 



By the Same Author. 

Poisons in Relation to Medical Jurisprudence and Medicine. Third 
American, from the third and revised English edition : In one large octavo volume of 788 
pages. Cloth, $5.50 ; leather, $6.50. 

JPEPPER, AUGUSTUS J., M. S., M. B., E. R. C. 8., 

Examiner in Forensic Medicine at the University of London. 
Forensic Medicine. In one pocket-size 12mo. volume. Preparing. See Student? 
Series of Manuals, page 4. 

LEA, HENRY C. 

Superstition and Force : Essays on The Wager of Law, The Wager of 
Battle, The Ordeal and Torture. Third revised and enlarged edition. In one 
handsome royal 12mo. volume of 552 pages. Cloth, $2.50. 



This valuable work is in reality a histo^ of civ- 
ilization as interpreted by the progress of jurispru- 
dence. . . In "Superstition and Force " we have a 
philosophic survey of the long period intervening 
between primitive barbarity and civilized enlightr 
enment. There is not a chapter in the work that 



should not be most carefully studied ; and however 
well versed the reader may be in the science of 
jurisprudence, he will find much in Mr. Lea's vol- 
ume of which he was previously ignorant. The 
book is a valuable addition to the literature of so- 
cial science.— Westminster Review, Jan. 1880. 



By the Same Author. 
Studies in Church History. The Rise of the Temporal Power— Ben- 
efit of Clergy — Excommunication. New edition. In one very handsome royal 
octavo volume of 605 pages. Cloth, $2.50. Just ready. 

The author is pre-eminently a scholar. He takes I primitive church traced with so much clearness, 
up every topic allied with the leading theme, and j and with so definite a perception of complex or 
traces it out to the minutest detail with a wealth j conflicting sources. The fifty pages on the growth 
of knowledge and impartiality of treatment that i of the papacy, for instance, are admirable for con- 
compel admiration. The amount of information ciseness and freedom from prejudice. — Boston 
compressed into the book is extraordinary. In no | Traveller, May 3, 1883. 
other single volume is the development of the ! 



Allen's Anatomy .... 

American Journal of the Medical Sciences 
American System of Gynecology . 

American System of Practical Medicine 

*Ashinirst's Sargery .... 

Ashvvell on Diseases of Women 

Attfleld's Chemistry .... 

Ball on the Rectum and Anns 

Barker's Obstetrical and Clinical Essays, 

Barlow's Practice of Medicine 

Barnes' Midwifery 

♦Barnes on Diseases of Women 

Barnes' System of Obstetric Medicine 

Bartholow on Electricity 

Basham on Renal Diseases . . 

Bell's Comparative Physiology and Anatomy 

Bellamy's Operative Surgery 

Bellamy's Surgical Anatomy 

Blandford on Insanity 

Bloxam's Chemistry 

♦Bristowe's Practice of Medicine . 

Broadbent on the Pulse 

Browne on the Ophthalmoscope . 

Browne on the Throat 

Bruce's Materia Medica and Therapeutics 

Brunton's Materia Medica and Therapeutics 

Bryant on the Breast .... 

♦Bryant's Practice of Surgery 

♦Bumstead on Venereal Diseases . 

♦Burnett on the Ear .... 

Butlin on the Tongue .... 

Carpenter on the Use and Abuse of Alcohol 

♦Carpenter's Human Physiology . 

Carter on the Eye .... 

Century of American Medicine 

Chambers on Diet and Regimen 

Charles' Physiological and Pathological Chem 

Churchill on Puerperal Fever 

Clarke and Lockwood's Dissectors' Manual 

Classen's Quantitative Analysis 

Cleland's Dissector .... 

Clouston on Insanity ... 

Clowes' Practical Chemistry 

Coats' Pathology .... 

Cohen on the Throat .... 

Coleman's Dental Surgery 

Condie on Diseases of Children 

Cooper's Lectures on Surgery 

Cornil on Syphilis .... 

♦Cornil and Ranvier's Pathological Histology 

Cullerier's Atlas of Venereal Diseases 

Curnow's Medical Anatomy 

Dal ton on the Circulation 

♦Dalton's HumanPhysiology 

Davis' Clinical Lectures 

Draper's Medical Physics 

Druitt's Modern Surgery 

Duncan on Diseases of Women 

♦Dunglison's Medical Dictionary . 

Edis'on Diseases of Women . 

Ellis' Demonstrations of Anatomy 

Emmet's Gynaecology 

♦Erichsen's System of Surgery 

Esmarch's Early Aid in Injuries and Accid'ts 

Farquharson's Therapeutics and Mat. Med. 

Fenwick's Medical Diagnosis 

Finlayson's Clinical Diagnosis 

Flint on Auscultation and Percussion 

Flint on Phthisis .... 

Elint on Physical Exploration of the Lungs 

Flint on Respiratory Organs 

Flint on the Heart 

♦Flint's Clinical Medicine 

Flint's Essays . . . 

♦Flint's Practice of Medicine 

Folsom's Laws of U. S. on Custody of Insane 

Foster's Physiology .... 

♦Fothergill's Handbook of Treatment . 

Fownes' Elementary Chemistry 

Fox on Diseases of the Skin . 

Frankland and Japp's Inorganic Chemistry 

Fuller on the Lungs and Air Passages 

Galloway's Analysis .... 

Gibney's Orthopaedic Surgery 

Gibson's Surgery .... 

Gluge's Pathological Histology, by Leidy 

Gould's Surgical Diagnosis . 

♦Gray's Anatomy ..... 

Greene's Medical Chemistry . 

Green's Pathology and Morbid Anatomy 

Griffith's Universal Formulary 

Gross on Foreign Bodies in Air-Passages 

Gross on Impotence and Sterility . 

Gross on Urinary Organs 

♦Gross' System of Surgery 

Habershon on the Abdomen 

♦Hamilton on Fractures and Dislocations 

Hamilton on Nervous Diseases 

Hartshorne's Anatomy and Physiology . 

Hartshorne's Conspectus of the Med. Sciences 

Hartshorne's Essentials of Medicine 

Hermann's Experimental Pharmacology 

Hill on Syphilis ..... 

Hillier's Handbook of Skin Diseases 

Hoblyn's Medical Dictionary 

Hodge on Women .... 

Hodge's Obstetrics .... 

Hoffmann and Power's Chemical Analysis 

Holden's Landmarks .... 



27 
15 

20 
28 
9 

4,21 
29 
18 
29 
27 
29 
17 
24 

4, 7 

4,20 
6 
19 
9 
14 

4,16 
23 
18 
11 
11 

4,21 
21 
25 
24 

4,21 



Holland's Medical Notes and Reflections 
♦Holmes' System of Surgery 

Horner's Anatomy and Histology 
Hudson on Fever 
Hutchinson on Syphilis 

Hyde on the Diseases of the Skin . 

Jones (C. Handheld) on Nervous Disorders 

J tiler's Ophthalmic Science and Practice 

Keating on infants 

King's Manual of Obstetrics 

Klein's Histology 

Land is on Labor .... 

La Roche on Pneumonia, Malaria, etc. . 

La Roche on Yellow Fever . 

Laurence and Moon's Ophthalmic Surgery 

Lawson on the Eye, Orbit and Eyelid 

Lea's Studies in Church History 

Lea's Superstition and Force 

Lee on Syphilis 

Lehmann s Chemical Physiology . 

♦Leishman's Midwifery 

Lucas on Diseases of the Urethra . 

Ludlow's Manual of Examinations 

Lyons on Fever ..... 

Maisch's Organic Materia Medica . 

Marsh on the Joints 

May on Diseases of Women . 

Medical News 

Medical News Visiting List . 

Medical News Physicians' Ledger . 

Meigs on Childbed Fever . . . 

Miller's Practice of Surgery . 

Miller's Principles of Surgery 

Mitchell's Nervous Diseases of Women . 

Morris on Diseases of the Kidney 

Morris on Skin Diseases 

Neill and Smith's Compendium of Med. Sci. 

Nettleship on Diseases of the Eye . 

Owen on Diseases of Children 

♦Parrish's Practical Pharmacy 

Parry on Extra-Uterine Pregnancy 

Parvin's Midwifery .... 

Pavy on Digestion and its Disorders 

Pepper's Forensic Medicine . 

Pepper's Surgical Pathology 

Pick on Fractures and Dislocations 

Pirrie's System of Surgery 

Playfair on Nerve Prostration and Hysteria 

♦Playfairs Midwifery . 

Politzer on the Ear and its Diseases 

Power's Human Physiology . 

Ralfe's Clinical Chemistry 

Ramsbotham on Parturition 

Remsen's Theoretical Chemistry . 

♦Reynolds' System of Medicine 

Richardson's Preventive Medicine 

Roberts on Urinary Diseases 

Roberts' Compend of Anatomy . 

Roberts' Principles and Practice of Surgery 

Robertson's Physiological Physics 

Ross on Nervous Diseases 

Sargent's Minor and Military Surgery . 

Savage on Insanity, including Hysteria . 

Schafer's Essentials of Histology, 

Schafer's Histology 

Schreiber on Massage . 

Seiler on the Throat, Nose and Naso-Pharynx 

Series of Clinical Manuals . . . 

Simon's Manual of Chemistry 

Skey's Operative Surgery 

Slade on Diphtheria .... 

Smith (Edward) on Consumption . 

Smith (PI. H.) and Horner's Anatomical Atlas 

♦Smith (J. Lewis) on Children 

Stllie on Cholera .... 

♦Stille & Maisch's National Dispensatory 

*Still6's Therapeutics and Materia Medica 

Stimson on Fractures .... 

Stimson's Operative Surgery 

Stokes on Fever ..... 

Students' Series of Manuals . 

Sturges' Clinical Medicine 

Tanner on Signs and Diseases of Pregnancy 

Tanner's Manual of Clinical Medicine . 

Taylor on Poisons .... 

♦Taylor's Medical Jurisprudence . 

Taylor's Prin. and Prac. of Med. Jurisprudence 

♦Thomas on Diseases of Women 

Thompson on Stricture 

Thompson on Urinary Organs 

Tidy's Legal Medicine . ... 

Todd on Acute Diseases 

Treves' Surgical Applied Anatomy 

Treves on Intestinal Obstruction . 

Tuke on the Influence of Mind on the Body 

Visiting List, The Medical News . 

Walshe on the Heart .... 

Watson's Practice of Physic . 

♦AVells on the Eye .... 

West on Diseases of Childhood 

West on Diseases of Women 

West on Nervous Disorders in Childhood 

Williams on Consumption . 

Wilson's Handbook of Cutaneous Medicine 

Wilson's Human Anatomy . 

Winckel on Pathol, and Treatment of Childbed 

Wohler's Organic Chemistry 

Woodhead's Practical Pathology . 

Year-Books of Treatment for 1884 and 1885 



Books marked * are also bound in half Kussia. 



L.EA BROTHERS & CO., Philadelphia. 



